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BUSINESS SERVICES CORPORATION D/B/A BENEFIT CHOICES SMALL GROUP PLANS 10/30/2023 12:22 PM2024 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN - Small Business 2 to 100 RATES COVER REGION 1: ALBANY *** Items in red are change from 2023METAL TIERPLAN CODEPlan Name Tier Monthly RateAggregate / EmbeddedDEDUCTIBLE (SINGLE/FAMILY)OFFICE VISIT SPECIALIST VISITINPATIENT HOSPITALOUTPATIENT SURGERYER URGENT CAREPRESCRIPTION DRUGS ****OOP MAX (SINGLE/FAMILY)Platinum 120 EPO Copayment Individual Empl/Spouse Parent/Child(ren) Family$1,063.29 $2,126.58 $1,807.59 $3,030,38N/A INN $0/$0 $15$20$500 $50 $100 $35$4/$30/$60 $7,500/$15,000Platinum 121 EPO CopaymentIndividual Empl/Spouse Parent/Child(ren) Family$1,066.14 $2,132.28 $1,812.44 $3,038.50N/AINN $0/$0 $20 $20 $750$25$100$50 $4/$30/$60 $7,350/$14,700Platinum 130EPO Copayment Individual Empl/Spouse Parent/Child(ren) Family$1,056.73 $2,113.46 $1,796.44 $3,011.68N/AINN $0/$0 $15 $35 $500$50$100$60 $4/$30/$60 $4,000/$8,000Gold 220EPO Copayment Individual Empl/Spouse Parent/Child(ren) Family$880.30 $1,760.60 $1,496.51 $2,508.86Embedded$750/$1,500Deductible, then $25 CopayDeductible, then $40 CopayDeductible, then $800 CopayDeductible, then $100 Copay Deductible, then $100 CopayDeductible, then $60 Copay$4/$30/$60; not subject to deductible$8,700/$17,400Gold 221Embrace Health EPO Copayment includes $200 bonus debit card **Individual Empl/Spouse Parent/Child(ren) Family$880.15 $1,760.30 $1,496.26 $2,508.43Embedded $250/$500Deductible, then $30Deductible, then $50Deductible, then $1,500Deductible, then $150Deductible, then $200Deductible, then $70 Copay $10/$50/$80; not subject to deductible$9,100/$18,200Gold 224Triple Zero HMO Copayment Individual Empl/Spouse Parent/Child(ren) Family$841.64 $1,683.28 $1,430.79 $2,398.67N/A $0/$0$0 Enhanced Primary Care Physician $50 Non-EPC$50$1,500 $200 $500 $100 $0/$50/$80 $8,700/$17,400Gold 225HDEPO HSA QUALIFIED Individual Empl/Spouse Parent/Child(ren) Family$881.68 $1,763.36 $1,498.86 $2,512.79Aggregate $1,600/$3,200Deductible, then $20 CopayDeductible, then $20 CopayDeductible, then $250 CopayDeductible, then $200 CopayDeductible, then $150 CopayDeductible, then $65 CopayDeductible, then $10/$30/$50$5,500/$11,000AGGREGATE: For any policy with two or more members, the deductible must be met by any one or any combination of members before the plan makes payments.EMBEDDED: Each member must meet their individual deductible before plan makes payments. The individual deductible also applies to family deductible level. Once family deductible is met, plan begins payment of services for all contract members.PEDIATRIC DENTAL: A pediatric dental rider is automatically added to subscribers that have children under the age of 19. Rates will be as noted above plus $16.49 per child enrolled (Albany Region) (up to a maximum of 3). If you have a standalone dental plan, you can sign a waiver to have CDPHP remove the pediatric dental rider.**EMBRACE EPO DEBIT CARD: To use your debit card, log into CDPHP to choose your path (fitness, medical or nutrition).To ensure coverage, check Find-a-Doc and confirm provider is in-network. Network Search: EPO or HDEPO includes Centers of Excellence and national providers. HMO includes providers in 26 counties in and around the Capital region***REGION 1 rates ALBANY includes the following counties:Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington.****50% Cost share for participating pharmacies not in preferred RX networkNOTE: In case of a discrepancy in the display of these plan details and rates, The carrier's actual plan details and rates prevail.

BUSINESS SERVICES CORPORATION D/B/A BENEFIT CHOICES SMALL GROUP PLANS 10/30/2023 12:22 PM2024 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN - Small Business 2 to 100 RATES COVER REGION 1: ALBANY *** Items in red are change from 2023METAL TIERPLAN CODEPlan Name Tier Monthly RateAggregate / EmbeddedDEDUCTIBLE (SINGLE/FAMILY)OFFICE VISIT SPECIALIST VISITINPATIENT HOSPITALOUTPATIENT SURGERYER URGENT CAREPRESCRIPTION DRUGS****OOP MAX (SINGLE/FAMILY)Silver 320 HDEPO HSA QualifiedIndividual Empl/Spouse Parent/Child(ren) Family$747.88 $1,495.76 $1,271.40 $2,131.46Aggregate$2,200/$4,400Deductible, then $30 CopayDeductible, then $40 CopayDeductible, then $1,500 Copay Deductible, then $200 CopayDeductible, then $500 Copay Deductible then $60 Deductible, then $10/$50/$80$7,050/$14,100Silver 324HDHMO HSA Qualified Individual Empl/Spouse Parent/Child(ren) Family$713.97 $1,427.94 $1,213.75 $2,034.81Aggregate $2,500/$5,000Deductible, then $25Deductible, then $50Deductible, then $500Deductible, then $200Deductible, then $300Deductible then $60Deductible, then $10/$40/$60$6,500/$13,000Silver 332HDEPO EPC Non- Qualified Individual Empl/Spouse Parent/Child(ren) Family$730.93 $1,461.86 $1,242.58 $2,083.15Embedded$5,000/$10,000$0 Enhanced Primary Care Physician $40 Non-EPCDeductible, then $60Deductible, then $750 Deductible, then $200Deductible, then $500 Deductible then $100 $15/$50/$80 $8,750/$17,500Silver 425Copay First EPO ($3,000/$6,000) Individual Empl/Spouse Parent/Child(ren) Family$761.44 $1,522.88 $1,294.45 $2,170.10Embedded$6,000/$12,000 $30 $50 $500 $50 $75 $60 $10/$30/$50 $6,000/$12,000Bronze 421 HDEPO HSA QualifiedIndividual Empl/Spouse Parent/Child(ren) Family$663.62 $1,327.24 $1,128.15 $1,891.32Aggregate $7,050/$14,100Deductible, then 0% CoinsuranceDeductible, then 0% CoinsuranceDeductible, then 0% CoinsuranceDeductible, then 0% CoinsuranceDeductible, then 0% CoinsuranceDeductible then 0% Coins.Deductible, then 0%/0%/0%$7,050/$14,100Bronze 424HDEPO HSA QualifiedIndividual Empl/Spouse Parent/Child(ren) Family$661.01 $1,322.02 $1,123.72 $1,883.88Aggregate$6,100/$12,200 Deductible, then $40 CoinsuranceDeductible, then $60 CoinsuranceDeductible, then $1,000 CoinsuranceDeductible, then $175 CoinsuranceDeductible, then $350 CoinsuranceDeductible then $80 Deductible, then $10/$50/$80$7,200/$14,400Bronze 428 HDHMO HSA QualifiedIndividual Empl/Spouse Parent/Child(ren) Family$602.34 $1,204.68 $1,023.98 $1,716.67Aggregate$6,350/$12,700Deductible, then 20%Deductible, then 20% Deductible, then 20% Deductible, then 20%Deductible, then 20%Deductible, then 20%Deductible, then 20%/20%/20%$7,200/$14,400AGGREGATE: For any policy with two or more members, the deductible must be met by any one or any combination of members before the plan makes payments.EMBEDDED: Each member must meet their individual deductible before plan makes payments. The individual deductible also applies to family deductible level. Once family deductible is met, plan begins payment of services for all contract members.PEDIATRIC DENTAL: A pediatric dental rider is automatically added to subscribers that have children under the age of 19. Rates will be as noted above plus $16.49 per child enrolled (Albany Region) (up to a maximum of 3). If you have a standalone dental plan, you can sign a waiver to have CDPHP remove the pediatric dental rider.To ensure coverage, check Find-a-Doc and confirm provider is in-network. Network Search: EPO or HDEPO includes Centers of Excellence and national providers. HMO includes providers in 26 counties in and around the Capital region***REGION 1 rates ALBANY includes the following counties:Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington.****50% Cost share for participating pharmacies not in preferred RX networkNOTE: In case of a discrepancy in the display of these plan details and rates, The carrier's actual plan details and rates prevail.