Page 32 - 2016-2021-OSU

reimbursed up to a lifetime maximum of $1500, not subject to deductible or

coinsurance.

(s) The Empire Plan medical carrier shall continue to contract with
Diabetes Education Centers accredited by the American Diabetes Education

Recognition Program.
§9.6 Empire Plan Mental Health and Substance Abuse

(a) The Empire Plan shall continue to provide comprehensive coverage
for medically necessary mental health and substance abuse treatment

services through a managed care network of preferred mental health and
substance abuse care providers. Network and non-network benefits shall be

those in effect on March 31, 2016, unless specifically modified by this
agreement. The outpatient mental health and substance abuse treatment

copayment(s) shall continue to equal the participating provider office visit
copayment. Covered expenses for mental health and/or substance abuse

treatment will be included in the combined deductibles and coinsurance
maximums set forth in Section 9.5 a and b of the Agreement.

(b) A disease management program for depression, eating disorders,
including appropriate nutritionist services, and ADHD will be available.

§9.7 Empire Plan Benefits Management Program
The current Benefits Management Program for CSEA employees enrolled

in the Empire Plan shall remain in effect unless modified by the Joint
Committee on Health Benefits.

(a) The Empire Plan Benefits Management Program's Prospective
Procedure Review requirement will include MRI, CAT and PET Scans,

Nuclear Medicine and MRA’s.

(b) Any day deemed inappropriate for an inpatient setting and/or not
medically necessary will be excluded from coverage under the Empire Plan.
§9.8 Empire Plan Home Care Advocacy Program

The current Home Care Advocacy Program (HCAP) for CSEA employees

enrolled in the Empire Plan shall continue. Individuals who fail to have
medically necessary designated HCAP services and supplies pre-certified

by calling HCAP and/or individuals who use a non-network provider will
receive reimbursement at 50 percent of the HCAP allowance for all services,

equipment and supplies upon satisfying the basic medical annual
deductible. In addition, the basic medical out-of-pocket maximum will not

apply to HCAP designated services, equipment and supplies. All other

31