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 If you use tobacco and have been diagnosed with a tobacco-related disease or are taking medicine that may be aff ected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable inpatient or outpatient cost sharing. Each counseling attempt includes up to four face-to-face visits. Urgently needed care Urgently needed care is care provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Covered supplemental services include: • World Wide Coverage What you must pay when you get these services Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service If you have been diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is aff ected by tobacco: In Network: $0 copayment for each Medicare-covered service Out of Network: 25% of the Medicare allowable amount for each Medicare-covered service If you reside in New York, Queens, Kings, Richmond, Bronx, Westchester, Rockland and Nassau, you pay In and Out-of-Network: $30 copayment for each visit If you reside in Suff olk, you pay: In and Out-of-Network: $25 copayment for each visit 77
78 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 Vision care Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts. • For people who are at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes, and African- Americans who are age 50 and older: glaucoma screening once per year. • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefi t after the fi rst surgery and purchase two eyeglasses after the second surgery.) Corrective lenses/frames (and replacements) needed after a cataract removal without a lens implant. Covered supplemental services include: • One pair of eyeglasses or contact lenses per year. Eyewear and contact lenses are from a limited Davis Vision Selection. • One routine vision exam per year What you must pay when you get these services If you reside in New York, Queens, Kings, Richmond or Bronx counties, you pay: In Network: $40 copayment for each Medicare-covered eyewear after cataract surgery $0 copayment for each Medicare-covered exam $25 copayment for each routine vision exam $45 copayment for one pair of eyeglasses or contact lenses If you reside in Nassau, Rockland, Westchester and Suff olk counties, you pay: In-Network: $40 copayment for each Medicare-covered eyewear after cataract surgery $0 copayment for each Medicare-covered screening $20 copayment for each routine vision exam $40 copayment for one pair of eyeglasses or contact lenses
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55 Water Street, New York, New York
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PPO II - EmblemHealth

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