PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II) II
SECTION Chapter 4: 3 Medical What benefi Benefi ts ts are Chart not (what covered is covered by the plan? and what you pay)
Services that are covered for you
“Welcome to Medicare” Preventive Visit
Th e plan covers the one-time “Welcome to Medicare” preventive visit.
Th e visit includes a review of your health, as well as education and
counseling about the preventive services you need (including certain
screenings and shots), and referrals for other care if needed.
Important: We cover the “Welcome to Medicare” preventive visit only
within the fi rst 12 months you have Medicare Part B. When you make
your appointment, let your doctor’s offi ce know you would like to
schedule your “Welcome to Medicare” preventive visit.
What you must
pay when you get
these services
79
For all counties, you
pay:
Out of Network:
50% of the Medicare
allowable amount for
each Medicare-covered
eyewear after cataract
surgery
50% of the Medicare
allowable amount for
each Medicare-covered
exam
25% of the Medicare
allowable amount for
each routine vision exam
50% of the plan
allowable amount for
each pair of eyeglasses or
contact lenses
In Network:
Th ere is no coinsurance,
copayment, or
deductible for the
“Welcome to Medicare”
preventive visit.
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
visit