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facilities;

• A travel allowance; and

• Paid-in-full reimbursement for all services provided at a Cancer
Resource Services network facility when the care is pre-certified.

(o) The Empire Plan medical carrier will continue a network of prosthetic
and orthotic providers. Prostheses or orthotics obtained through an

approved prosthetic/orthotic network provider will be paid in full under the
participating provider component of the Empire Plan, not subject to

copayment. For prostheses or orthotics obtained other than through an

approved prosthetic/orthotic network provider, reimbursement will be made
under the basic medical component of the Empire Plan, subject to deductible
and coinsurance.

If more than one prosthetic or orthotic device can meet the individual's

functional needs, benefits will be available for the most cost-effective piece
of equipment. Benefits are provided for a single-unit prosthetic or orthotic

device except when appropriate repair and/or replacement of devices are
needed.

(p) A Basic Medical Provider Discount Program will be available through
the basic medical component of the Empire Plan.

• Empire Plan enrollees will have access to an expanded network of
providers through an additional provider network;

• Basic Medical provisions will apply to the providers in the expanded
network option (deductible and 20% coinsurance);

• Payment will be made by the Plan directly to the discount providers,

no balance billing of discounted rate will be permitted;
• This program is offered as a pilot program and will terminate on

December 31, 2017, unless extended by agreement of both parties.

(q) An annual diabetic shoe benefit will be available through the Home
Care Advocacy Program under the medical carrier. Network coverage:
Benefits paid at 100% with no out of pocket cost up to $500 maximum.

Non-network Coverage: For diabetic shoes obtained other than through the

Home Care Advocacy Program, reimbursement will be made under the
basic medical component of the Empire Plan, subject to deductible and the

remainder paid at 75% of the network allowance, up to maximum allowance
of $500.

(r) Prosthetic wigs shall be a covered basic medical benefit and shall be

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