953 Back   2003 Health Benefit Agreement

Deductibles and Co-Pay

(e) With respect to Plan participants and their beneficiaries who live in an area where they may choose between CHCB and MMCP coverage, the percentage of Covered Expenses (Eligible Expenses) payable by the Plan with respect to an individual covered under the CHCB will be 75% until the Out-of-Pocket Maximum is reached, but only 60% if a required notice to Medical Management (Care Coordination/Patient Management) is not given or if Medical Management (Care Coordination/Patient Management) determines that the service or supply involved is not Medically Appropriate.

(f) The Individual and Family Out-of-Network Deductibles under the Planís MMCP will be increased to $200 and $600, respectively.

(g) The Planís Prescription Drug Card Program co-payments per prescription are revised as follows: (i) Generic Drug - $5.00; (ii) Brand Name Drug - $10.00. The Planís Mail Order Prescription Drug Program co-payment is revised as follows: (i) Generic Drug - $10.00; (ii) Brand Name Drug - $15.00.