CPC - 4.2026 Benefits Guide

MEDICAL BENEFITS

HIP SELECT CARE LOW PLAN IN - NETWORK ONLY

HIP PRIME HMO HIGH PLAN IN - NETWORK ONLY

HOW TO FIND A NETWORK MEDICAL PROVIDER

• Go to www.EmblemHealth.com • Click “ Find a Doctor ” • Under “ Find a Doctor ” click “ Find Care ” • Click “ Search by Network or Plan ” • Scroll down to select “ HIP HMO - Select Care ” or “ HIP Prime HMO - Prime ” • Click “ Go ” • Scroll down to select the type of provider you are searching • Enter the “ Zipcode ” of the area you want to search then click “ Next ”

BENEFIT

IN - NETWORK

OUT - OF - NETWORK

Specialist Referrals Required

Yes

Yes

Annual Deductible

Individual: None Family: None Individual: $6,850 Family: $13,700

Individual: None Family: None Individual: $6,850 Family: $13,700

Out - of - Pocket Maximum

Coinsurance

HIP pays 100%; You pay 0%

HIP pays 100%; You pay 0%

Preventive Care Adult Annual Physical Exam Well - Child Care

No charge No charge

No charge No charge

Inpatient Care

$2,000 copay per admission

$2,000 copay per admission

Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery

$30 copay $75 copay $750 copay No charge No charge No charge

$30 copay $75 copay $750 copay No charge No charge No charge

Laboratory Services Diagnostic Services Advanced Imaging (PET Scan, MRI, Nuclear Medicine, CAT Scans) Emergency Care Ambulance when medically necessary At hospital emergency room (waived if admitted) Urgent Care Maternity Care Prenatal and Post - natal care Hospital services for mother and child

No charge $500 copay

No charge $500 copay

$30 copay

$30 copay

No charge $1,000 copay

No charge $1,000 copay

Mental Health Inpatient Outpatient

$2,000 copay $30 copay

$2,000 copay $30 copay

Durable Medical Equipment (precertification required) Optical Care Refractive Eye Exams Eyeglasses (every 24 months) Prescription Drugs Retail Pharmacy (30 day supply) Mail Order (90 day supply)

No charge after $500 deductible

No charge after $500 deductible

$35 copay $35 copay

$35 copay $35 copay

$15 copay Generic ONLY $22.50 copay Generic ONLY

$15 copay Generic ONLY $22.50 copay Generic ONLY

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail. QUESTIONS? Call BenefitsVIP at 866.293.9736

4