Lisette M. Johnson NYSDFS
EmblemHealth-Silver-CSR3-2021-Schedule-of-Benefits Section XXVI Schedule of Benefits EmblemHealth Silver CSR 3
COST-SHARING
Deductible · Individual · Family
Participating Provider Non-Participating Provider
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$0
None
$0
None
Out-of-Pocket Limit · Individual · Family
OFFICE VISITS
Primary Care Office Visits (or Home Visits)
$1,000 $2,000
Participating Provider Member Responsibility for Cost-Sharing $10 Copayment
Non-Participating Provider services are not covered except as required for Emergency Care
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
Specialist Office Visits (or Home Visits)
Referral Required
$20 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
1 155-23-IONHIXS100Schedule (04/20)
PREVENTIVE CARE
· Well Child Visits and Immunizations*
Participating Provider Member Responsibility for Cost-Sharing Covered in full
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
· Adult Annual Physical Covered in full Examinations*
Non-Participating Provider services are not covered and You pay the full cost
· Adult Immunizations* Covered in full
Non-Participating Provider services are not covered and You pay the full cost
· Routine Gynecological Covered in full Services/Well Woman Exams*
· Mammograms,
Covered in full
Screening and
Diagnostic Imaging for
the Detection of Breast
Cancer*
· Sterilization Procedures for Women*
Covered in full
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
· Vasectomy
See Surgical Services Cost-Sharing
Non-Participating Provider services are not covered and You pay the full cost
· Bone Density Testing* Covered in full
Non-Participating Provider services are not covered and You pay the full cost
2 155-23-IONHIXS100Schedule (04/20)
PREVENTIVE CARE Continued
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
· Screening for Prostate Covered in full Cancer
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
· All other preventive services required by USPSTF and HRSA.
Covered in full
Non-Participating Provider services are not covered and You pay the full cost
· *When preventive services are not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA.
EMERGENCY CARE
Pre-Hospital Emergency Medical Services (Ambulance Services) Non-Emergency Ambulance Services
Use Cost-Sharing for appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures and Diagnostic Testing) Participating Provider Member Responsibility for Cost-Sharing $50 Copayment
$50 Copayment
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider Member Responsibility for Cost-Sharing $50 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
See benefit for description
Emergency Department Copayment waived if admitted to Hospital
Urgent Care Center
$50 Copayment
$50 Copayment
Health care forensic examinations performed under Public Health Law § 2805-i are not subject to Cost-Sharing $30 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
See benefit for description
3 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Advanced Imaging Services
· Performed in a Specialist Office
Participating Provider Member Responsibility for Cost-Sharing
$20 Copayment
Non-Participating Provider Member Responsibility for Cost-Sharing
Non-Participating Provider services are not Covered and You pay the full cost
Limits
See benefit for description
· Performed in a Freestanding Radiology Facility
· Performed as Outpatient Hospital Services
$20 Copayment $20 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Preauthorization Required Allergy Testing and Treatment
See benefit for description
· Performed in a PCP Office
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· Performed in a Specialist Office
$20 Copayment
Referral Required Ambulatory Surgical Center Facility Fee
$25 Copayment
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Anesthesia Services (all settings)
Autologous Blood Banking
Covered in full 5% Coinsurance
Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
See benefit for description
4 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Cardiac and Pulmonary Rehabilitation
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
See benefit for description
· Performed in a Specialist Office
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· Performed as Outpatient Hospital Services
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· Performed as Inpatient Included as part of
Non-Participating Provider
Hospital Services
inpatient Hospital service services are not Covered and
Cost-Sharing
You pay the full cost
Preauthorization Required Chemotherapy and Immunotherapy
· Performed in a PCP Office
$10 Copayment
· Performed in a Specialist Office
$10 Copayment
· Performed as Outpatient Hospital Services
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Preauthorization Required
Chiropractic Services
$20 Copayment
Clinical Trials Preauthorization Required
Use Cost-Sharing for Appropriate Service
Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
See benefit for description
5 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Diagnostic Testing
· Performed in a PCP Office
· Performed in a Specialist Office Referral Required
· Performed as Outpatient Hospital Services Preauthorization Required
Dialysis
· Performed in a PCP Office
· Performed in a Specialist Office Referral Required
· Performed in a Freestanding Center Referral Required
· Performed as Outpatient Hospital Services Referral Required
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
$20 Copayment
Non-Participating Provider services are not covered and You pay the full cost
$20 Copayment
Non-Participating Provider services are not covered and You pay the full cost
$10 Copayment $10 Copayment $10 Copayment $10 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
See benefit for description
Dialysis performed by NonParticipating Providers is limited to 10 visits per calendar year Preauthorization
Required
Non-Participating Provider services are not Covered and You pay the full cost
6 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)
· Performed in a PCP Office
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$15 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Sixty (60) visits per condition per Plan Year. Combined therapies
· Performed in a Specialist $15 Copayment Office
Non-Participating Provider services are not covered and You pay the full cost
· Performed in an Outpatient Facility
$15 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Preauthorization Required
Home Health Care
$10 Copayment
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
Forty (40) visits per Plan Year
7 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Infertility Services
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
Use Cost-Sharing for appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory and Diagnostic Procedures)
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Preauthorization Required Infusion Therapy
· Performed in a PCP Office
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
· Performed in a Specialist Office Referral Required
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· Performed as Outpatient Hospital Services Preauthorization Required
· Home Infusion Therapy Preauthorization Required
Inpatient Medical Visits
$10 Copayment $10 Copayment $0 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Home infusion counts toward home health care visit limits
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
8 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Interruption of Pregnancy
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
· Medically Necessary Covered in full Abortions
Non-Participating Provider services are not Covered and You pay the full cost
Unlimited
· Elective Abortions Preauthorization Required
See Surgical Services Cost-Sharing
Non-Participating Provider services are not Covered and You pay the full cost
One (1) procedure per calendar Year
Laboratory Procedures
· Performed in a PCP Office
$10 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
See benefit for description
· Performed in a Specialist Office
$20 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
· Performed in a Freestanding Laboratory Facility
· Performed as Outpatient Hospital Services
$20 Copayment $20 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Preauthorization Required
9 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Maternity and Newborn Care
Participating Provider Member Responsibility for Cost-Sharing
· Prenatal Care · Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA · Prenatal Care that is not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA
Covered in full
Use Cost-Sharing for appropriate service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures and Diagnostic Testing)
Non-Participating Provider Member Responsibility for Cost-Sharing
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early
Covered for duration of breast feeding
· Inpatient Hospital Services and Birthing Center
$100 Copayment per admission
Non-Participating Provider services are not covered and You pay the full cost
· Physician and Midwife Services for Delivery
$25 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· Breastfeeding Support, Covered in full Counseling and Supplies, Including Breast Pumps
Non-Participating Provider services are not covered and You pay the full cost
· Postnatal Care
Preauthorization Required for Inpatient
Services Outpatient Hospital Surgery Facility Charge
Preauthorization Required
Included in Physician Non-Participating Provider and Midwife Services for services are not covered and Delivery Cost Sharing You pay the full cost
$25 Copayment
Non-Participating Provider services are not covered and You pay the full cost
155-23-IONHIXS100Schedule (04/20)
See benefit for description
10
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Preadmission Testing
Preauthorization Required
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$0 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Prescription Drugs Administered in Office
See benefit for description
· Performed in a PCP Office Included as part of the PCP office visit CostSharing
· Performed in Specialist Office
Included as part of the Specialist office visit Cost-Sharing
Diagnostic Radiology Services
· Performed in a PCP Office
$10 Copayment
· Performed in a Specialist Office Preauthorization Required
· Performed in a Freestanding Radiology Facility Preauthorization Required
· Performed as Outpatient Hospital Services Preauthorization Required
$20 Copayment $20 Copayment $20 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
See benefit for description
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
11 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Therapeutic Radiology Services
· Performed in a Specialist Office
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
· Performed in a Freestanding Radiology Facility
· Performed as Outpatient Hospital Services
$10 Copayment $10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Preauthorization Required Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)
· Performed in a PCP office
$15 Copayment
· Performed in a Specialist office
$15 Copayment
· Performed in an Outpatient Facility)
$15 Copayment
Preauthorization Required Second Opinions on the Diagnosis of Cancer, Surgery and Other
$20 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Sixty (60) visits per condition, per Plan Year. Combined therapies. Speech and physical therapy are only Covered following a Hospital stay or surgery.
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Referral Required
Second opinions on diagnosis of cancer are Covered at participating Cost-Sharing for non-participating Specialist when a Referral is obtained.
12 155-23-IONHIXS100Schedule (04/20)
PROFESSIONAL SERVICES and OUTPATIENT CARE Continued Surgical Services (including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive and Corrective Surgery; and Transplants)
Participating Provider Member Responsibility for Cost-Sharing
Non-Participating Provider Member Responsibility for Cost-Sharing
Limits
See benefit for description
· Inpatient Hospital Surgery
$25 Copayment
· Outpatient Hospital Surgery
$25 Copayment
· Surgery Performed at an Ambulatory Surgical Center
$25 Copayment
· Office Surgery · Performed in a PCP Office
$10 Copayment
· Performed in a Specialist Office
$20 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
All transplants must be performed at designated Center of Excellence Facilities
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Preauthorization Required Telemedicine Program
$0 Copayment
Non-Participating Provider
not subject to Deductible services are not Covered and
You pay the full cost
See benefit for description
13 155-23-IONHIXS100Schedule (04/20)
ADDITIONAL SERVICES, EQUIPMENT and DEVICES ABA Treatment for Autism Spectrum Disorder
Participating Provider Member Responsibility for Cost-Sharing $10 Copayment
Preauthorization Required
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
Assistive Communication
$10 Copayment
Devices for Autism Spectrum
Disorder
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Preauthorization Required Diabetic Equipment, Supplies and Self-Management Education
· Diabetic Equipment, Supplies and Insulin (30-day supply)
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
· Diabetic Education
$10 Copayment
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
14 155-23-IONHIXS100Schedule (04/20)
ADDITIONAL SERVICES, EQUIPMENT and DEVICES (Continued) Durable Medical Equipment and Braces
Participating Provider Member Responsibility for Cost-Sharing 5% Coinsurance
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
See benefit for description
Preauthorization Required
External Hearing Aids
5% Coinsurance
Preauthorization Required
Cochlear Implants
5% Coinsurance
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Single purchase once every three (3) years
One (1) per ear per time covered
Hospice Care · Inpatient
· Outpatient
$100 Copayment per admission
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
210 days per Plan Year
Five (5) visits for family bereavement counseling
Preauthorization Required
Medical Supplies
5% Coinsurance
Preauthorization Required
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
15 155-23-IONHIXS100Schedule (04/20)
ADDITIONAL SERVICES, EQUIPMENT and DEVICES Continued Prosthetic Devices
Participating Provider Member Responsibility for Cost-Sharing
Non-Participating Provider Member Responsibility for Cost-Sharing
· External
5% Coinsurance
Non-Participating Provider services are not covered and You pay the full cost
· Internal
Preauthorization Required
INPATIENT SERVICES and FACILITIES
Inpatient Hospital for a Continuous Confinement (including an Inpatient Stay for Mastectomy Care, Cardiac and Pulmonary Rehabilitation, and End of Life Care)
Included as part of
Non-Participating Provider
inpatient Hospital service services are not covered and
Cost-Sharing
You pay the full cost
Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
One (1) prosthetic device, per limb, per lifetime with coverage for repairs and replacements
Unlimited; See benefit for description Limits
See benefit for description
Preauthorization required. However, Preauthorization is not required for emergency
admissions or services provided in a neonatal intensive care unit of a Hospital certified pursuant to Article 28 of the Public Health
Law.
Observation Stay
$50 Copayment
Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation)
$100 Copayment per admission
Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
200 days per Plan Year
Preauthorization Required Inpatient Habilitation Services (Physical, Speech and Occupational Therapy)
$100 Copayment per admission
Preauthorization Required
155-23-IONHIXS100Schedule (04/20)
Non-Participating Provider services are not Covered and You pay the full cost
Sixty (60) days per Plan Year. Combined therapies
16
INPATIENT SERVICES and FACILITIES Continued Inpatient Rehabilitation Services (Physical, Speech and Occupational therapy)
Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Limits
Sixty (60) days per Plan Year. Combined therapies.
Preauthorization Required
MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care for a continuous confinement when in a Hospital (including Residential Treatment)
Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission
Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost
Speech and physical therapy are only Covered following a Hospital stay or surgery Limits
See benefit for description
Preauthorization Required. However, Preauthorization
is not required for emergency admissions or
for admissions at Participating OHM-licensed
Facilities for Members under 18.
Outpatient Mental Health Care (including Partial Hospitalization and Intensive Outpatient Program Services)
See benefit for description
· Office Visits
$10 Copayment
· All Other Outpatient $10 Copayment Services
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
17 155-23-IONHIXS100Schedule (04/20)
MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES Continued Inpatient Substance Use Services for a continuous confinement when in a Hospital (including Residential Treatment)
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$100 Copayment per admission
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Preauthorization Required. However, Preauthorization
is not Required for Emergency Admissions or for Participating OASAS-
certified Facilities. Outpatient Substance Use Services (including Partial Hospitalization, Intensive Outpatient Program Services, and Medication Assisted Treatment)
Unlimited; Up to 20 visits per calendar year may be used for family counseling
· Office Visits
$10 Copayment
Non-Participating Provider services are not covered and You pay the full cost
· All Other Outpatient $10 Copayment Services
Non-Participating Provider services are not covered and You pay the full cost
18 155-23-IONHIXS100Schedule (04/20)
PRESCRIPTION DRUGS
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
*Certain Prescription Drugs are not subject to CostSharing when provided in accordance with the comprehensive guidelines supported by HRSA or if the item or service has an "A" or "B" rating from the USPSTF and obtained at a participating pharmacy. Retail Pharmacy 30-day supply Tier 1
$6.00Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Tier 2
$15.00 Copayment
Tier 3
$30.00 Copayment
Preauthorization is not required for a Covered Prescription Drug used to treat a substance use disorder, including a Prescription Drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal.
19 155-23-IONHIXS100Schedule (04/20)
PRESCRIPTION DRUGS (Continued)
Mail Order Pharmacy Up to a 90-day supply Tier 1
Tier 2
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$15.00 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
$37.50 Copayment
Tier 3 Enteral Formulas Tier 1
Tier 2
$75.00 Copayment $6.00 Copayment $15.00 Copayment
Non-Participating Provider services are not covered and You pay the full cost
See benefit for description
Tier 3 WELLNESS BENEFITS
Gym Reimbursement
$30.00 Copayment
Participating Provider Member Responsibility for Cost-Sharing $200 per six (6)-month calendar year period; $100 per six (6)-month calendar year period for covered Dependent(s)
Non-Participating Provider Member Responsibility for Cost-Sharing $200 per six (6)-month calendar year period; $100 per six (6)-month calendar year period for covered Dependent(s)
Limits
$200 per six (6)-month calendar year period; $100 per six (6)month calendar year period for covered Dependent(s)
20 155-23-IONHIXS100Schedule (04/20)
PEDIATRIC VISION CARE Pediatric Vision Care
· Exams
· Lenses and Frames
· Contact Lenses
Participating Provider Member Responsibility for Cost-Sharing
$10 Copayment
5% Coinsurance
Non-Participating Provider Member Responsibility for Cost-Sharing
Non-Participating Provider services are not covered and You pay the full cost
Non-Participating Provider services are not covered and You pay the full cost
Limits
One (1) exam per 12-month period; One (1) prescribed lenses and frames per 12month period
5% Coinsurance
Non-Participating Provider services are not covered and You pay the full cost
21 155-23-IONHIXS100Schedule (04/20)
PEDIATRIC DENTAL CARE
· Preventive Dental Care
· Routine Dental Care
· Major Dental Care (Endodontics, Periodontics, Prosthodontics and Oral Surgery)
· Orthodontics
Participating Provider Non-Participating Provider Limits
Member Responsibility Member Responsibility for
for Cost-Sharing
Cost-Sharing
$10 Copayment $10 Copayment $10 Copayment
$10 Copayment
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
Non-Participating Provider services are not Covered and You pay the full cost
One (1) Dental Exam & Cleaning Per six (6)-Month Period
Full mouth Xrays or panoramic Xrays at thirtysix (36) month intervals and bitewing Xrays at six (6) month intervals.
Major Dental Care and Orthodontics require Preauthorization
All in-network Preauthorization requests are the responsibility of Your Participating Provider. You will not be penalized for a Participating Provider's failure to obtain a required Preauthorization. However, if services are not covered under the Certificate, You will be responsible for the full cost of the services.
Eligible American Indians, as determined by the NYSOH, are exempt from Cost-Sharing requirements when Covered Services are rendered by an Indian Health Service, Indian Tribe, Tribal Organization or Urban Indian Organization, or through Referral under contract health services.
22 155-23-IONHIXS100Schedule (04/20)
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