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covered spouse/domestic partner and $1,875 for one or all dependent

children. The coinsurance maximums will include out-of-pocket expenses

for covered hospital, medical, mental health and substance abuse services.
The coinsurance maximums will not include out-of-pocket expenses for

covered home care advocacy program services as set forth in Section 9.8
of this Agreement nor covered managed physical medicine services as set

forth in Section 9.9 of this Agreement.
(c) If there are no participating providers available within the GeoAccess

standards established under Article 9.30, access to network benefits will be
made available to enrollees for primary care physicians and core provider

specialties as agreed under Article 9.30.
(d) Employees 50 years of age or older and their covered

spouses/domestic partners 50 years of age or older will be eligible for
reimbursement of up to 100% of reasonable and customary charges toward

the cost of a routine physical examination provided by a non-participating
physician. These benefits shall not be subject to deductible or coinsurance.

(e) The cost of certain injectable adult immunizations shall be a covered
expense, subject to copayment(s), if any, under the participating provider

portion of the Empire Plan. As established by the 2010 Federal Patient
Protection and Affordable Care Act, no copayment shall be required for the

following: Influenza, Pneumococcal, Measles, Mumps, Rubella, Varicella,
Meningoccocal (meningitis), Tetanus, Diptheria, Pertussis (Td/Tdap),

Hepatitis A, Hepatitis B, Human Papilloma Virus and Herpes Zoster
Shingles (for age 60 or older) and shall be subject to protocols developed

by the medical program carrier.

(f) Routine pediatric care, including well child office visits, physical
examinations and pediatric immunizations, for children up to age 19 will
be covered under the basic medical program, subject to deductible or

coinsurance. Influenza vaccine is included on the list of pediatric

immunizations, subject to appropriate protocols, under the participating
provider and basic medical components of the Empire Plan. Preventive
care services as established by the 2010 Federal Patient Protection and

Affordable Care Act will be covered in full when an individual utilizes a

Participating Provider.
(g) Routine newborn services covered under the basic medical

component shall not be subject to deductible or coinsurance.

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