GHI-Healthy NY EPO High Deductible Health Plan

Cost Sharing
Annual Plan Deductible	$1,250 Individual / $2,500 Family for plan year 2013*
Annual Out-of-Pocket Maximum	$6,050 Individual / $12,100 Family for plan year 2013*

This is a high deductible plan. With the exception of Well baby and well child care, Adult  Preventive Care Services, and Pre-natal care, the deductible must be satisfied before EmblemHealth will provide coverage for covered services. The family deductible amount applies if the policy covers more than one person. The family deductible may be satisfied by one individual family member or by expenses incurred by various family members. However, the entire plan year deductible must be satisfied before services will be covered for any member of the family.  Out-of-pocket maximum expenses include the deductible and copayments paid for HNY benefits covered by this plan. Once the out-of-pocket maximum for the plan year is reached, no further copayments will apply and covered benefits will be covered in full. The family out-of-pocket maximum amount applies if the policy covers more than one person.

*Note: The deductible and out-of-pocket amounts are subject to change each year based on Treasury guidelines.

Plan Details

Inpatient Hospital Services*	In Network	Out of Network
Hospital Coverage	$500 Copayment per continuous confinement	Not Covered (except for emergency)
Skilled Nursing	Not Covered	Not Covered
Maternity and Routine Nursery Care	Covered in Full	Not Covered
Hospice Care	Not covered	Not Covered
Outpatient Hospital Services*	In Network	Out of Network
Ambulatory Surgery	$75 Facility Copayment	Not Covered
Home Health Care	$20 Copayment – up to 40 post-hospital or post-surgical visits per year	Not Covered
Medical Services	In Network	Out of Network
Surgical Services	20% or $200, whichever is less	Not Covered
Delivery	20% or $200, whichever is less	Not Covered
Home and Office Visits	$20 Copayment	Not Covered
Physical Check-up (once every 3 years)	Covered in Full	Not Covered
Chiropractic Care	Not Covered	Not Covered
Physical Therapy	$20 Copayment – up to 30 post-hospital or post-surgical visits per year	Not Covered
Speech Therapy	Not Covered	Not Covered
Well-baby and Well-child Care	Covered in Full	Not Covered
Lab and Radiology Services	In Network	Out of Network
Diagnostic Lab Tests and Radiology Procedures	$20 Copayment	Not Covered
Emergency Services	In Network	Out of Network
ER Professional Charge	Covered in Full	Allowed charge
Emergency Facility Charge (Waived if Admitted)	$50 Copayment per visit	$50 Copayment per visit
Mental Health and Chemical Dependency Services*	In Network	Out of Network
Inpatient Mental Health	Not Covered	Not Covered
Inpatient Chemical Dependency Treatment (Detoxification)	Not Covered	Not Covered
Chemical Dependency Treatment (Rehabilitation)	Not Covered	Not Covered
Outpatient Chemical Dependency Treatment	Not Covered	Not Covered
Outpatient Mental Health	Not Covered	Not Covered
Pharmacy (Optional)	In Network	Out of Network
Pharmacy	Retail Copayment: $10 per generic drug per 34-day supply, $20 per brand name drug plus difference in cost between the brand name drug and its generic equivalent per 34-day supply. Mail Order Copayment: $20 per generic drug per 90-day supply, $40 per brand name drug per 90-day supply plus the difference in cost between the brand name drug and its generic equivalent. Benefit Maximum: Unlimited.	Not Covered

* Services may be subject to Precertification or Pre-authorization.

The benefits described here are only brief highlights of the coverage available. Some benefits may have calendar year limits and/or maximums. The terms, limitations, conditions, and exclusions of the insurance contract and certificate will govern.