Other Benefits Included in Your CDPHP Plan

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1 Other Benefits Included in Your CDPHP Plan Enhanced Wellness Benefit Makes Healthy Choices More Affordable CDPHP offers reimbursement for up to $500 per contract, per year, for wellness-related activities, including gym memberships, youth sports programs (subject to maximum reimbursement of $100), weight loss programs that include exercise, and more. Simply submit the Enhanced Wellness Benefit Form available at Pediatric dental and vision coverage Pediatric dental and vision coverage is required for small business plans under the Affordable Care Act (ACA). For pediatric dental coverage: CDPHP will ensure you receive this required benefit through a Delta Dental Pediatric Plan. If you and/or your dependent(s) have the required coverage elsewhere and you wish to disenroll from the Delta Dental Pediatric Plan, you can complete the Essential Pediatric Dental Coverage Attestation Form in this packet. For pediatric vision coverage: Pediatric vision exams are subject to the plan deductible.* If the deductible has been met, the eye exam will be the equivalent of the primary care physician (PCP) visit cost share. Pediatric vision hardware is not subject to the plan deductible. If the deductible has been met, the hardware will be the equivalent of the durable medical equipment (DME) cost share. Adult Vision Coverage Most CDPHP plans** cover one routine adult vision exam and offer a vision hardware allowance. If your plan covers vision care and has a deductible, here is how it works: Adult eye exams are subject to the plan deductible.* The eye exam will be the equivalent of the specialist visit cost share. Adult vision hardware is not subject to the plan deductible, and you can receive reimbursement for up to $75 for lenses, frames, or contacts. To receive hardware reimbursement, simply submit a medical claim. You can download the form from and mail it to the address provided on the form. Additional details about adult vision coverage can be found in the Other Covered Services section of your certificate. Non-standard plans also entitle you to reimbursement for up to $750 for LASIK eye surgery (including the pre-consultation). Simply submit the LASIK Reimbursement Form available at Please refer to your contract and schedule for cost-share information. * Vision exams are not subject to the deductible with hybrid plans. ** Not available with standard plans. Please refer to your employer or your Schedule of Benefits to determine if this coverage is available to you. Capital District Physicians Health Plan, Inc. CDPHP Universal Benefits, Inc. 500 Patroon Creek Boulevard, Albany, NY (518) or up to $ 500 reimbursement for gym memberships and more!

2 Rx for Less: 100 Pills for as Little as With Rx for Less, CDPHP members with prescription drug benefits can get deep discounts on specified generic drugs when purchased at any CVS, Hannaford, Price Chopper, ShopRite, or Walmart. $1 Effective March 4, 2015 Drugs and prices below are subject to change at anytime. Rx For Less Price Drug Label Name Maximum Quantity for Max. Rx Quantity ANTI-INFLAMMATORY IBUPROFEN 400 MG, 600 MG, 800 MG TAB 100 $1.00 INDOMETHACIN 25 MG CAP 100 $1.00 MELOXICAM 7.5 MG, 15 MG TAB 100 $1.00 NAPROXEN 375 MG, 500 MG, 550 MG TAB 100 $1.00 ASTHMA ALBUTEROL NEB 0.083% 150 $5.00 IPRATROPIUM NEB 0.2 MG/ML 150 $3.00 BEHAVIORAL HEALTH BUSPIRONE 5 MG, 10 MG TAB 100 $1.00 CITALOPRAM 20 MG, 40 MG TAB 100 $1.00 FLUOXETINE 10 MG, 20MG CAP 100 $1.00 PAROXETINE 10 MG, 20MG TAB 100 $1.00 RISPERIDONE 0.25 MG, 0.5 MG, 1 MG, 2 MG TAB 100 $1.00 SERTRALINE 25 MG, 50 MG, 100 MG TAB 100 $1.00 TRAZODONE 50 MG, 100 MG, 150 MG TAB 100 $1.00 VENLAFAXINE 37.5 MG, 75 MG, 150 MG CAP SR 24HR 100 $1.00 BLOOD THINNER WARFARIN/JANTOVEN 1 MG - 10 MG TAB 100 $1.00 CARDIAC/ BLOOD PRESSURE ACE INHIBITORS BENAZEPRIL HCL 5 MG, 10 MG, 20 MG, 40 MG TAB 100 $1.00 ENALAPRIL MALEATE 2.5 MG, 5 MG, 10 MG, 20 MG TAB 100 $1.00 ENALAPRIL-HCTZ MG, MG TAB 100 $1.00 FOSINOPRIL SODIUM 10 MG, 20MG, 40 MG TAB 100 $1.00 LISINOPRIL 2.5 MG, 5 MG, 10 MG, 20 MG, 30 MG, 40 MG TAB 100 $1.00 LISINOPRIL-HCTZ MG, MG, MG TAB 100 $1.00 QUINAPRIL 5 MG, 10 MG, 20 MG, 40 MG TAB 100 $5.00 QUINAPRIL-HCTZ MG, MG TAB 100 $5.00 RAMIPRIL 1.25 MG, 2.5 MG, 5 MG, 10 MG CAP 100 $5.00 ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) IRBESARTAN TAB 75 MG, 150 MG, 300 MG TAB 100 $25.00 LOSARTAN POTASSIUM 25 MG, 50 MG, 100 MG TAB 100 $10.00 BETA-BLOCKERS ATENOLOL 25 MG, 50 MG, 100 MG TAB 100 $1.00 ATENOLOL-CHLORTHAL MG, MG TAB 100 $1.00 BISOPROLOL-HCTZ MG, MG, MG TAB 100 $1.00 CARVEDILOL MG, 6.25 MG, 12.5 MG, 25 MG TAB 100 $1.00 METOPROLOL TARTRATE 25 MG, 50 MG, 100 MG TAB 100 $1.00 PROPRANOLOL 10 MG, 20 MG, 40 MG, 80 MG TAB 100 $1.00 Maximum Quantity Rx For Less Price for Max. Rx Quantity Drug Label Name CALCIUM CHANNEL BLOCKERS AMLODIPINE 5 MG, 10 MG TAB 100 $10.00 DILTIAZEM 30 MG, 60 MG, 90 MG, 120 MG TAB 100 $1.00 VERAPAMIL 80 MG, 120 MG TAB 100 $1.00 DIURETICS AMILORIDE HCL-HCTZ 5-50 MG TAB 100 $10.00 BUMETANIDE 0.5 MG, 1 MG, 2MG TAB 100 $1.00 FUROSEMIDE 20 MG, 40 MG, 80 MG TAB 100 $1.00 HYDROCHLOROTHIAZIDE 12.5 MG CAP 100 $1.00 HYDROCHLOROTHIAZIDE 25 MG, 50 MG TAB 100 $1.00 SPIRONOLACTONE 25 MG, 50 MG TAB 100 $1.00 TRIAMTERENE-HCTZ MG CAP 100 $1.00 TRIAMTERENE-HCTZ MG, MG TAB 100 $1.00 CHOLESTEROL (STATINS) ATORVASTATIN 10 MG, 20 MG TAB* 90 $14.99 ATORVASTATIN 40 MG TAB* 90 $19.99 ATORVASTATIN 80 MG TAB* 90 $29.99 LOVASTATIN 10 MG, 20 MG TAB* 90 $1.00 LOVASTATIN 40 MG TAB* 90 $5.00 PRAVASTATIN SODIUM 10 MG TAB * 90 $10.00 PRAVASTATIN SODIUM 20 MG TAB * 90 $15.00 PRAVASTATIN SODIUM 40 MG TAB * 90 $20.00 SIMVASTATIN 10 MG TAB* 90 $5.00 SIMVASTATIN 20 MG, 40 MG, 80 MG TAB* 90 $10.00 DIABETES GLIMEPIRIDE 1 MG, 2 MG, 4 MG TAB 100 $1.00 GLIPIZIDE 5 MG, 10 MG TAB 100 $1.00 GLIPIZIDE XL 2.5 MG, 5 MG, 10 MG TAB 100 $1.00 GLYBURIDE 1.25 MG, 2.5 MG, 5 MG TAB 100 $1.00 GLYBURIDE MICRO 3 MG, 6 MG TAB 100 $1.00 METFORMIN HCL 500 MG, 850 MG, 1,000 MG TAB 100 $1.00 METFORMIN HCL ER 500 MG, 750 MG TAB 100 $1.00 GOUT ALLOPURINOL 100 MG, 300 MG TAB 100 $1.00 OSTEOPOROSIS ALENDRONATE SODIUM 35 MG, 70 MG TAB ** 12 $3.00 STEROIDS PREDNISONE 5 MG, 10 MG TAB 100 $1.00 VITAMINS/SUPPLEMENTS FOLIC ACID 1 MG TAB 100 $1.00 * Price shown is for 90-day supply. ** Dosing schedule for Alendronate is 1 tab per week. Price shown is for 12 tabs (90-day supply). Rx for Less pricing is not applicable to mail-order drugs. CDPHP Universal Benefits, Inc. Capital District Physicians Health Plan, Inc. Capital District Physicians Healthcare Network, Inc Form#

3 SMALL BUSINESS Earning Rewards is Easy!* Here are just some of the ways you can earn Life Points. For a full list, go to and sign in to the secure member website. Select the Life Points Member Rewards site. Step 1: Unlock your Life Points To start earning Life Points, your first step is to view the Learn Your Benefits online tutorial, available when you log in. Once you have completed this step, you will be able to accumulate points for your healthy activities. Step 2: Start earning points 20 points per milestone To earn points, you can choose from a variety of activities, including: Getting a vaccination Completing an annual physical exam Attending a free CDPHP wellness class Getting a flu shot Working out using CDPHP InMotion SM And more! Go to and sign in to the secure site to learn more. * All adults age 18 and older in select plans are eligible. Points worth up to $180 are allowed per calendar year, per contract. Points must be redeemed by December 31 each year. Capital District Physicians Health Plan, Inc. Capital District Physicians Healthcare Network, Inc. CDPHP Universal Benefits, Inc

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5 ExtraCare Health Card Discount-Eligible Items The ExtraCare Health card offers a 20 percent discount* on more than 1,300** CVS/pharmacy brand products. The following are examples of some of the categories and items eligible for the ExtraCare Health discount. This list is not all inclusive and is subject to change. allergy remedies Decongestant Allergy Relief Loratidine (compare to Claritin ) Cetirizine (compare to Zyrtec ) BaBy care Diaper Rash Ointment Digital Thermometer cold remedies Cough Suppressant Cough Drops Anti-bacterial Wipes Cold and Flu Relief Cold and Sinus Relief Children s Cold and Allergy Elixir Decongestant Digital Thermometer Nasal Spray Lozenges eye & ear care Contact Lens Solution Eye Drops Pink Eye Relief Ear Wax Remover Ear Plugs First aid Rubbing Alcohol Adhesive Strips Dressings Antibacterial Ointment Hydrocortisone Cream Burn Relief Cotton Gauze Hand Sanitizer Hot and Cold Packs Peroxide Pain Relieving Patches HOme diagnostics Alcohol Preps Glucose Test Strips Gauze Pads Needles Auto-Injectors Blood Pressure Cuff Glucose Meter Lancets Glucose Tablets Pedometer nicotine replacements Nicotine Gum Nicotine Patches (Continued) * The 20 percent discount is restricted to items purchased for the cardholder, spouse, or dependents. ** Excludes prescriptions, alcohol, tobacco, lottery tickets, postage stamps, gift cards, money orders, pre-paid cards, photofinishing, and CVS.com purchases, and are not valid on other items reimbursed by a governmental program.

6 Oral Hygiene Anti-plaque Mouthwash Oral Anesthetic Dry Mouth Relief Cold Sore Treatment Pain Relievers Acetaminophen Aspirin Children s Aspirin Migraine Relief Ibuprofen Naproxen Sleep Aids Stomach Remedies Antacid Acid Reducer Fiber Supplements Laxatives Motion Sickness Relief Pink Bismuth Medicare members, be advised that these products and services are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the CDPHP grievance process. CDPHP Universal Benefits, Inc. Capital District Physicians Health Plan, Inc Capital District Physicians Healthcare Network, Inc

7 SECTION XIV Wellness Benefits A. Diabetic Wellness Program 1. Purpose: The purpose of this wellness program is to encourage You to take a more active role in managing Your health and well-being if you are a diabetic. 2. Description We provide benefits in connection with the following use of or participation in any of the following wellness and health promotion actions and activities: Self-management of diabetes. 3. Eligibility. You, the Subscriber, and Your Covered Spouse and Children can participate in the wellness program. 4. Participation. The preferred method for accessing the wellness program is through our website. You need to have access to a computer with Internet access in order to participate in the website program; however, if You do not have access to a computer, please call us at (518) or and we will provide You with information regarding how to participate on an offline basis. 5. Rewards. Rewards for participation in a wellness program include: the waiver or reduction of Copayments, Coinsurance or Deductibles. monetary rewards in the form of cash, gift cards or gift certificates, so long as the recipient is encouraged to use the reward for a product or service that promotes good health, such as healthy cook books, over the counter vitamins or exercise equipment. B. General Wellness Program. 1. Purpose. The purpose of this wellness program is to encourage You to take a more active role in managing Your health and well-being. 2. Description. We provide benefits in connection with the use of or participation in any of the following wellness and health promotion actions and activities: Designated healthy activities Self-management of chronic diseases Gym Membership, Fitness, and Exercise Classes: We will reimburse you for the price of gym or fitness club memberships with proof of attendance Form # (SGEPONSTDNEXHSMART)

8 for activities listed on Examples of qualifying activities include: Fitness Club Memberships (including family memberships) Exercise Classes (e.g. Spinning, Pilates, Tai Chi, Yoga, jui jitsu, Karate) Entry Fees (Race, Tournament) Personal Training Sessions Fitness or Weight Loss Camps Family YMCA or fitness facility fees The following do NOT qualify for reimbursement: Equipment- Purchase or Rental Clothing or Electronics Merchandise (including Videos/DVD's) Publications Gift Certificates Fees and expenses related to motorized sports (e.g. snowmobiling) Dues (e.g. Country Club) Golf Tee Time, fees, or Range Usage Tennis Court Time Lodging, food, spa therapy or other non-fitness related activities Physical activities at country clubs. such as swimming or exercise classes, must be billed or itemized separately from membership fees and/or dues to qualify for reimbursement. Strictly social memberships do not qualify for reimbursement. B. Youth Sports and Fitness Fees We will reimburse you for youth sport and fitness fees for Eligible Dependents up to the age of 19 for up to $100 maximum per Calendar Year with proof of attendance, if applicable. Qualifying Activities Include: Fitness Club membership Organized Sports Fees Sport Camps or Leagues Swimming and Diving Lessons Entry Fees (Race, Tournament) Personal Training Sessions Weight Loss Programs/Camps The following do NOT qualify for reimbursement Equipment- Purchase or Rental Clothing or Electronics Merchandise (including Videos/DVD's) Publications Gift Certificates Fees and expenses related to motorized sports (e.g. snowmobiling) Dues (e.g. Country Club) Golf Tee Time or Range Usage Tennis Court Time Form # (SGEPONSTDNEXHSMART)

9 Room and board, spa therapy or other non-fitness related activities Physical activities at country clubs or social clubs, such as swimming or exercise classes, must be billed or itemized separately from membership fees and/or dues to qualify for reimbursement. Strictly social memberships do not qualify for reimbursement. C. Chronic Disease Prevention and Self-Management Support We will reimburse you for the following approved weight loss programs Weight Watchers (In person or 3 month online program) Nutritional Counseling visits with a Registered Dietician (reimbursement for out of pocket costs) Diabetes Prevention Program (DPP) Fee-based Smoking Cessation programs Other approved evidence-based chronic disease prevention and management programs listed on The following do NOT qualify for reimbursement: Dietary Supplements Diet Plans/Programs NOT listed above Merchandise (including Videos/OVD's) Publications Gift Certificates Clothing or Electronics Room or Board, and Food other than that purchased directly from a program listed above. 3. Eligibility. You, the Subscriber, each covered Dependent can participate in the wellness program. 4. Participation. The preferred method for accessing the wellness program is through Our website at You need to have access to a computer with internet access in order to participate in the website program. However, if You do not have access to a computer, please call Us at the phone number on Your ID card and We will provide You with information regarding how to participate without internet access. Whichever wellness activities You select, using licensed, certified, and reputable programs help ensure easy, prompt reimbursement upon submission of the required materials. You will need to submit an original, paid receipt for any wellness activity listed above, along with a completed Form. This form can be found in your member packet or on the web at by searching for Wellness Program. It can also be requested from our Member Services center at phone number listed on Your ID Card. 5. Rewards. Reimbursement We will reimburse you for the approved programs listed about up to a maximum of five hundred ($500.00) per Contract per Plan Year, with a maximum of one hundred ($100) for children and teen sports programs included within the $500 per maximum. Reimbursement for the above services apply to the Calendar Year in which the service is paid. Form # (SGEPONSTDNEXHSMART)

10 Reimbursement cannot be combined with any other monetary reimbursement from CDPHP. You are responsible for any tax consequences related to reimbursement for any of the activities described above. Rewards for participation in a wellness program include: The waiver or reduction of Copayments, Deductibles or Coinsurance. Form # (SGEPONSTDNEXHSMART)

11 CDPHP Enhanced Wellness Benefit This benefit is included with all small business and individual health plans. Some large business employers may also purchase this added benefit for their employee plan. Please refer to your member contract to determine your eligibility. The Enhanced Wellness Benefit offers eligible members the opportunity to be reimbursed up to $500 per contract each year for wellness-related activities, such as fitness programs and chronic disease prevention programs. This benefit also includes reimbursement for children and teen sports programs, up to a maximum of $100. Your contract contains further details on eligible expenses. Some examples include: Gym/Fitness Chronic Disease Prevention Gym/fitness club memberships, including YMCA Weight Watchers (in-person/online) Exercise classes (e.g., spinning, Pilates, yoga, karate) Diabetes Prevention Program (DPP) Swimming lessons Fee-based smoking cessation programs Personal training sessions Some examples that do NOT qualify are: equipment purchase or rental, clothing, gift certificates, publications, golf tee times, tennis court times, spa therapy, country clubs, and dietary supplements. To request reimbursement, participate in a qualified program and submit this completed form along with the appropriate paperwork, including: 1. A copy of the bill showing the cost of the program 2. A receipt showing full payment Please submit one form per person, per request. You are only eligible for reimbursement for expenses that were incurred during your plan benefit year. Additional forms are available online at or by calling member services at the number on your member ID card. Subscriber Name: Member ID #: Date of Birth: Address: Phone: Dependent Name (If not applicable, list self ): Dependent Member ID # + Suffix: Is dependent under 18? Yes No Facility/Program Information: Facility Name: Address: Facility Employee Name: Facility Employee Signature: Phone: Title: Date: Certification and Authorization (must be signed by the subscriber) Reimbursement is subject to approval by Capital District Physicians Health Plan, Inc. I certify that the information on the form and all supporting documents are complete, accurate, and unaltered, and that I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for eligible members. I certify that these expenses have not previously been reimbursed in this or any other year. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. Subscriber Signature: Date: Please mail this form and all supporting documents to: CDPHP P.O. Box Albany, NY Capital District Physicians Health Plan, Inc. CDPHP Universal Benefits, Inc