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- 7. Changes : Additional Copays & Limits on Benefits 50% (up to $1,000 -except oxygen) 50% - No $ Limit Durable Medical Equipment 50 days - $500 copay 50 days - $0 copay Skilled Nursing $75 $10/$15 Outpatient Surgery $100 $50 Emergency Room/Ambulance 50% (up to $1,000 -except post-mastectomy) Not Covered Prosthetic/Orthotic Appliances 19/25 19/19 Dependent/Student (Albany) 7 days detox Not Covered IP Alcohol/Substance Abuse $500 $0 Inpatient Copay HMO 101/102 HMO 202/203