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
What you must
pay when you get
these services
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for each
Medicare-covered lab
service, x-ray and blood
$25 - $50 copayment
for each Medicare
covered diagnostic test
20% of the plan
allowable amount for
surgical supplies such
as dressings, splints and
casts
$50 copayment for
each Medicare-covered
radiation therapy service
A separate offi ce
copayment of
$15 - $25 may apply
for outpatient
radiation therapy
For all counties, you
pay:
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
lab service, x-ray and
blood
25% for each Medicare
covered diagnostic test
30% of the Medicare
allowable amount
for Medicare-covered
surgical supplies such
as dressings, splints and
casts