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
Podiatry services
Covered services include:
• Diagnosis and the medical or surgical treatment of injuries and
diseases of the feet (such as hammer toe or heel spurs).
• Routine foot care for members with certain medical conditions
aff ecting the lower limbs
Covered supplemental services include:
• Up to 4 routine visits every year. Benefi t includes removal of calluses
and corns, and trimming of nails
What you must
pay when you get
these services
For all counties, you
pay:
Out of Network:
25% of the Medicare
allowable amount
for each primary care
doctor or specialist visit
for Medicare-covered
benefi ts.
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for each
Medicare covered visit
$30 copayment for each
routine visit
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for each
Medicare covered visit
$25 copayment for each
routine visit
For all counties, you
pay:
Out of Network:
$40 copayment for each
Medicare covered visit
$40 copayment for each
routine visit