SUMMARY OF BENEFITS

CHARTER 10 POINT OF SERVICE

PACE UNIVERSITY

AS ADMINISTERED BY HEALTH NET

EFFECTIVE DATE: January 1, 2004

Customer Service # 1-800-205-0095 http://www.health.net/

BENEFITS	IN-NETWORK ^1		OUT-OF-NETWORK ^2
Financial
Deductible:	None		$300 Single, $600 Two Person, $900 Family
Max. Out-of-Pocket Cost: (Does not include charges in excess of allowed amount or non-covered benefits)	$1,000 Single, $2,000 Family		$1,800 Single, $3,600 Family
Max. Lifetime Benefit Per Member	$2,000,000 combined in-network/out-of-network lifetime maximum
Prescription Drugs
Coverage (Note: oral contraceptives, contraceptive devices and Norplant are covered as part of the member’s prescription drug coverage, subject to the applicable copayment) Mail Order, for a 90 day supply: Member must use Express-Scripts Mail Order form or enroll online at www.express-scripts.com.	Retail $10 Copayment per Generic per prescription $20 Copayment per Brand Name $30 Copayment per Non Formulary prescription Mail Order $10 Copayment per Generic prescription $20 Copayment per Brand Name $30 Copayment per Non Formulary prescription		Outside Service Area: Covered as in-network if the member uses the Advanced Paradigm, Inc. (API Network). If the member uses a non API pharmacy, prescriptions will be covered, subject to the medical deductible and co-insurance.
Preventive Care
Routine Physical Exams - Children Through Age 18	$15 Copayment in accordance with HEALTH NET’s schedule of covered well exam		Covered In-Network Only
Adults Age 19 and Over	$15 Copayment in accordance with HEALTH NET’s schedule of covered well exam		Covered In-Network Only
Routine Preventive Immunizations	$15 Copayment per Visit		Covered In-Network Only
Routine Gynecological Care	$15 Copayment per Visit, members age 15 and older are covered for one pap test and one pelvic exam per calendar year		Covered In-Network Only
Maternity Care
Pre-Natal & Post-Natal (from effective date of HEALTH NET’S coverage).	No Cost after 1st Visit with a $15 Copayment		70% of UCR
Hospital Services for Mother & Child (includes all newborn costs even if mother is discharged and newborn requires continued hospitalization)	No Cost		70% of Hospital Charges
Family Planning and Infertility Services (includes in-vitro fertilization and GIFT)^3	$15 Copayment per Visit		70% of UCR
Outpatient Care
Physician Office Visits		$15 Copayment per Visit	70% of UCR
X-rays & Laboratory Tests		No Cost	70% of UCR
Physical & Occupational Therapy, Including Chiropractic Care^3		$15 Copayment per Visit	70% of UCR
Cardiac Rehabilitation		$15 Copayment per Visit	70% of UCR
Speech Therapy, for up to 90 consecutive days^3		$15Copayment per Visit	70% of UCR
Allergy Services		$15 Copayment per Visit	70% of UCR
Diagnostic Procedures and/or Surgery Performed in a Hospital or Outpatient Surgical Care^3		No Cost	70% of Hospital Charges

BENEFITS	IN-NETWORK ^1	OUT-OF-NETWORK ^2
Vision Care
Routine Eye Exams	$15 Copayment per Visit; One Visit per Member per 24 Months	Covered In-Network Only
Eyeglasses, including frames, lenses, etc.	$200 combined allowance	$200 combined allowance
Medical Care for Illness or Injury to the Eye	$15 Copayment per Visit	70% of UCR
Inpatient Care
Semi-Private Room and Board^3	No Cost	70% of Hospital Charges
Physicians', Surgeons’ and Nursing Services and Medications^3	No Cost	70% of UCR
Special-Duty Nursing^3	No Cost for up to 70 shifts per member per year	70% of UCR
Restorative Physical & Occupational Therapy^3	No Cost	70% of Hospital Charges
Mental Health, Drug/Alcohol Addiction
Outpatient Visits, up to 30 Outpatient Visits per Member per Year Combined - All Services^4	$20 Copayment per Visit Mental Health services require Prior Authorization after the 6^th visit^3	50% of charges per Visit/Session
Inpatient Days Exchangeable with Partial Hospitalization Sessions up to 30 Days per Member per Year^4	No Cost Mental Health services require Prior Authorization ^3	70% at HEALTH NET Approved Facilities
Home Health or Hospice Care
Physician House Calls	$15 Copayment per Visit	70% of UCR
Home Health Care When Skilled Services are Required^3	No Cost; 200 Visits per Calendar Year	70% in Lieu of Hospitalization
Inpatient Hospice Care^3	No Cost	70% of UCR
Other Services
Durable Medical Equipment ^3	No Cost	70% of Cost of Covered Item
Prosthetics (maximums are combined in and out of network) ^- Internal ^- External, to a maximum of $5,000 for the first appliance	No Cost No Cost	70% of UCR 70% of UCR
Gym Membership	Discount	Covered In Network Only
Massage	Discount	Covered In Network Only
Acupuncture, for up to 20 visits per year	$25 Copayment per Visit	Covered In Network Only
Emergency Care
At Physicians Office	$15 Copayment per Visit	$15 Copayment per Visit
Urgent Care at an Urgent Care Center	$15 Copayment per Visit	$15 Copayment per Visit
At Hospital Emergency Room	$15 Copayment per Visit	$15 Copayment per Visit
Limiting Age
Dependents are covered to the end of the month in which the eligible dependent reaches age 19. If the eligible dependent is 19 or over, and is a full-time student, coverage will extend to the earlier of the end of the month in which the eligible dependent graduates, ceases to be a full-time student, or reaches age 25.

1 In Network services are services and benefits provided or arranged by a HEALTH NET participating provider.

2 Out of Network services require a member to pay a deductible and coinsurance.

3 When medically necessary and approved in advance by HEALTH NET.

4. Substance Abuse - when medically necessary and approved in advance.

Copayment Maximum: All of your in-network copayments will be applied to the annual copayment maximum of $1,000 per member or $2,000 per family per calendar year.

Out-of-Network Benefits: When using Out-of-Network benefits, precertification is required for all inpatient and outpatient hospital admissions, all elective ambulatory surgical procedures, and most diagnostic procedures received in a non-plan hospital or free-standing surgical center. To obtain precertification, please contact the HEALTHNET Customer Service Department at 1-800-205-0095. A $200 penalty is applied to Out-of-Network reimbursement when the member does not complete the precertification process.

General Exclusions: This plan does not cover physical exams for employment, insurance, school, premarital requirements or summer camp (unless substituted for a normal physical exam); prescription drugs and some injectables dispensed by a physician in his or her office; prescription drugs prescribed for a non-covered service; dental services; routine foot care; some transplant procedures; cosmetic or reconstructive surgery, unless medically necessary; custodial services; weight-reduction programs; marriage counseling; or psychiatric treatment which is above and beyond the guidelines as determined to be clinically acceptable.

The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Pace University plan documents are the final arbiter of coverage under the plan. If you have any questions, please call the HEALTHNET Customer Service Dept. at 1-800-205-0095 or contact the Pace University Benefits Office at 1-914-923-2763.