PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Medical Chapter Benefi 4: Medical ts Chart Benefi ts Chart (what is covered and what you pay) Services that are covered for you Dental services In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover: Covered supplemental services include: • One routine exam per year • One cleaning per year Depression screening We cover 1 screening for depression per year. Th e screening must be done in a primary care setting that can provide follow-up treatment and referrals. Diabetes screening We cover this screening (includes fasting glucose tests) if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. What you must pay when you get these services In Network: $0 copayment for exam $0 copayment for cleaning Out of Network: 50% of the plan allowable amount for a cleaning and exam In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service 55
56 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 Diabetes self-management training, diabetic services and supplies For all people who have diabetes (insulin and non-insulin users). Covered services include: • Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucosecontrol solutions for checking the accuracy of test strips and monitors Members are eligible to receive the following diabetic meters, and the associated lancets and test strips: - Freestyle Lite, lancets and test strips - Freestyle Freedom Lite, lancets and test strips - Precision Xtra, lancets and test strips - Precision Q-I-D, lancets and test strips Th e benefi t is administered under Part B. • For people with diabetes who have severe diabetic foot disease: One pair per calendar year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fi tting. Diabetes self-management training is covered under certain conditions Durable medical equipment and related supplies * Prior authorization is required on certain items, such as motorized wheelchairs. Contact Customer Service for a complete list. (For a defi nition of “durable medical equipment,” see Chapter 12 of this booklet.) What you must pay when you get these services In Network: $0 copayment for each Medicare-covered Diabetes training $0 copayment for each Medicare-covered Diabetic supply Out of Network: 25% of the Medicare allowable amount for Medicare-covered Diabetes training 30% of the Medicare allowable amount for Medicare-covered Diabetic supplies In Network: 20% of the plan allowable amount for Medicare-covered items Out of Network: 30% of the Medicare allowable amount for Medicare-covered items
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55 Water Street, New York, New York
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PPO II - EmblemHealth

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