PPO II - EmblemHealth

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
Outpatient substance abuse services
* Prior authorization is required through Value Options at
1-866-318-7595 before the fi rst visit.
* Th e initial prior authorization will be good for the fi rst 5 visits. After 5
visits, additional prior authorization must be obtained.
What you must
pay when you get
these services
For all counties, you
pay:
Out of Network:
50% of the Medicare
allowable amount for
each Medicare-covered
visit
69
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for
each Medicare-covered
individual or group visit
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for
each Medicare-covered
individual or group visit
For all counties, you
pay:
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
individual or group visit