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ConsumerDirect EPO (51 +)
EmblemHealth high deductible health plans (HDHPs) feature lower premiums based on a higher than usual annual deductible and offer a separate health savings account or health reimbursement arrangement that members own and can use for future medical expenses with tax-free dollars.
Plan Overview
Choice
We respect that different people have different needs. That's why we offer members a choice of affordable, quality plans with extensive benefit packages that provide real value:
Many plans to choosefrom and a selection of deductibles to meet member needs.
Affordability
Members pay no out-of-pocket costs for covered preventive care in-network, including routine physicals, screenings, immunizations, mammograms, gynecological exams and well-baby care. These services are not subject to the plan's deductible. 1
Low network pharmacy copay. $0 for generic, $20 for preferred, and $40 for nonpreferred prescription drugs after the plan's annual deductible is met.
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 like 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 c
Quit smoking programs.
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.
Also available, subject to your group's plan, are: 3Timely reminders about flu shots and diagnostic testing, such as mammograms and prostate exams.
A Nurse Advice Line that members may call 24/7 to speak with a Registered Nurse.
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 ConsumerDirect EPO , there are generally no claims forms to file. Our network providers do the work for you.
24/7 customer service.Easy-to-use online tools, available at our secure web site, www. emblemhealth.com, make it easy for members to manage their account activity, balances, and savings growth. In addition, members may access provider listings, eligibility, claims status, benefits, and more online 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 |
|---|---|
| Office Visit | Deductible & Coinsurance |
| Annual Physical Check-up | Covered in Full |
| Preventive Mammography, Pap Smear, Prostate Screening | Covered in Full |
| Well-Baby and Well-Child Care | Covered in Full |
| Inpatient Hospital Services | Deductible & Coinsurance |
| Skilled Nursing Facility Care | Deductible & Coinsurance |
| Hospice Care - Inpatient and Outpatient | Deductible & Coinsurance |
| Ambulatory Surgery Facility | Deductible & Coinsurance |
| Home Health Care | Deductible & Coinsurance |
| Chiropractic Care | Deductible & Coinsurance |
| Diagnostic Lab and Radiology | Deductible & Coinsurance |
| Emergency Room Facility | Deductible & Coinsurance |
| Inpatient Mental Health Care | Deductible & Coinsurance |
| Outpatient Mental Health Care | Deductible & Coinsurance |
| Inpatient Chemical Dependency Care | Deductible & Coinsurance |
| Outpatient Chemical Dependency Care | Deductible & Coinsurance |
| Prescription Drugs | Deductible & Coinsurance |
1 Some services are subject to precertification.
2 EmblemHealth cannot ensure that a particular vendor will remain in the program. These programs are not covered services underwritten by Group Health Incorporated ("GHI") as part of the EmblemHealth ConsumerDirect EPO.
* Availability of health and wellness programs may vary based on the EmblemHealth product selected.
The EmblemHealth ConsumerDirect EPO program is underwritten by Group Health Incorporated ("GHI") and provides
in-network benefits only. Except for emergency hospital care, no out-of-network services are covered. 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 -997, et. al.
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