What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for failure to precertify out-of-network speech therapy. Coverage is limited to an annual max of 35 visits for Physical therapy, Speech, Hearing & Occupational therapy and 35 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $250 penalty for failure to precertify out-of-network speech therapy. Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $250 penalty for no out-of-network precertification. Coverage is limited to 30 days annual max. $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
$60 copay/visit for Physical, Speech, Hearing & Occupational therapy** $60 copay/visit for Chiropractic care** **Deductible does not apply
40% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy 40% coinsurance/visit for Chiropractic care
Rehabilitation services
$60 copay/visit for Physical, Speech, Hearing & Occupational therapy** **Deductible does not apply
40% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy
Habilitation services
Skilled nursing care
20% coinsurance
40% coinsurance
Durable medical equipment 20% coinsurance
40% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
40% coinsurance/inpatient services 40% coinsurance/outpatient services
Hospice services
Children's eye exam Children's glasses
Not covered Not covered
Not covered Not covered
None None
If your child needs dental or eye care
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