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See covered drugs in our formulary.
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For plans that contain pharmacy coverage. Check the applicable benefits design or the certificate of insurance for more information.
InBalance PPO (2 - 50)
Plan Overview
Choice
We respect that different people have different needs. That's why we offer a choice of affordable, quality plans with extensive benefits that provide real value:
EmblemHealth PPO InBalance offers:
Outstanding provider choice from any in- or out-of network provider, with special cost-sharing requirements so members are offered the same provider choice as EmblemHealth PPO at lower cost.
Hospital, medical and prescription drug coverage
Benefits for most covered services out-of-network
No gatekeepers or referrals required
Several cost-saving options available
Affordability
No copay for childrenfor office visits or diagnostic tests performed in-network. All other members receive most covered in-network office-based services for just the cost of a copayment. 1
No copay for generic drugswhen members use network pharmacies.
Quality
Quality doctors. Our National network includes more than half the "Top Docs" from New York Magazine's list, and virtually every acute care hospital in the region--great hospitals l i e Memorial Sloan-Kettering, Montefiore Medical Center, Lenox Hill Hospital, North Shore- Long Island Jewish Health System, and Albany Medical Center. Health and Wellness Programs. We help members stay healthy with*:
Timely reminders about flu shots and diagnostic testing, such as mammograms and prostate exams.
Quit-smoking programs.
A Nurse Advice Line that members may call 24/7 to speak with a Registered Nurse.
Discounts on health-related services such as weight-loss programs, laser vision, and acupuncture.2
Confidential, professional counseling, education, and referral services through our 24/7 toll-free Employee Assistance Program (EAP) hotline.
Access to Care
Our National network provides access regionally to more than 106,000 doctors at more than 172,000 locations in New York, New Jersey, and Connecticut and to more than one million practitioners nationwide.Ease
Less paperwork.With EmblemHealth PPO and InBalance PPO, there are generally no claim forms to file for services received in-network.
24/7 customer service.Provider listings, eligibility, claims status, benefits, and
more are all available at www.emblemhealth.com or by calling our automated
phone system.
Respect
At EmblemHealth, we understand the things that matter to members about their health care coverage including respect for their time, intelligence, and money.
Plan Details
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| Services | in-network | out-of-network |
|---|---|---|
| Office Visits | Office Copayment | Deductible & Coinsurance |
| Office visits and diagnostic copay for dependent children/students | $0 | Deductible & Coinsurance |
| Annual Physical Check-up | Covered in Full | Deductible & Coinsurance |
| Preventive Mammography, Pap Smear, Prostate Screening | Covered in Full | Deductible & Coinsurance |
| Well-Baby and Well-Child Care | Covered in Full | Covered in Full |
| Inpatient Hospital Services | Deductible & Coinsurance | Deductible & Coinsurance |
| Skilled Nursing Facility Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Hospice Care - Inpatient and Outpatient | Deductible & Coinsurance | Covered In-Network Only |
| Ambulatory Surgery Facility | Deductible & Coinsurance | Deductible & Coinsurance |
| Home Health Care | 20% Coinsurance | 20% Coinsurance |
| Chiropractic Care | Office Copayment | Deductible & Coinsurance |
| Diagnostic Lab and Radiology | ||
| Facility | Deductible & Coinsurance | Deductible & Coinsurance |
| Office | Diagnostic Copayment | Deductible & Coinsurance |
| Emergency Room Facility | ER Facility Copayment | ER Copayment |
| Inpatient Mental Health Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Outpatient Mental Health Care | Office Copayment | Deductible & Coinsurance |
| Inpatient Chemical Dependency Care | Deductible & Coinsurance | Deductible & Coinsurance |
| Outpatient Chemical Dependency Care | Office Copayment | Deductible & Coinsurance |
| Vision Exam, Frames And Lenses For Children | $10 Copayment, $20 Copayment | |
| Prescription Drugs | Prescription Drug Copayment | Covered In-Network Only |
1 Some services are subject to precertification.
2 EmblemHealth cannot ensure that a particular vendor will remain in the program. The services available under these programs are not covered services underwritten by Group Health Incorporated ("GHI") as part of the EmblemHealth InBalance PPO.
* Availability of health and wellness programs may vary based on the EmblemHealth product selected.
Please note: If members choose non-network providers, their out-of-pocket costs will increase.
The EmblemHealth InBalance PPO program is underwritten by Group Health Inc. ("GHI"). Coverage
is subject to all terms, conditions, limitations, and exclusions set forth in the contract and certificate of insurance.
Refer to GHI policy form numbers PLH-SGC-991 et al.
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