PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II
Chapter 4: Medical Benefi ts Chart (what is covered Medical and what Benefi you ts Chart pay)
Services that are covered for you
Covered supplemental services include:
• Up to one additional pap test and pelvic exam each year.
Chiropractic services
* Prior Authorization from Palladian (1-877-774-7693) is required after
the 8th visit.
Covered services include:
• We cover only manual manipulati0on of the spine to correct
subluxation
Colorectal cancer screening
For people 50 and older, the following are covered:
• Flexible sigmoidoscopy (or screening barium enema as an alternative)
every 48 months
• Fecal occult blood test, every 12 months
For people at high risk of colorectal cancer, we cover:
• Screening colonoscopy (or screening barium enema as an alternative)
every 24 months
For people not at high risk of colorectal cancer, we cover:
• Screening colonoscopy every 10 years (120 months), but not within
48 months of a screening sigmoidoscopy
What you must
pay when you get
these services
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
service
25% of the Medicare
allowable amount for
each supplemental
service
In Network:
$20 copayment for each
Medicare-covered visit
Out of Network:
$40 copayment for each
Medicare-covered visit
In Network:
$0 copayment for
each Medicare-covered
service
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
service