What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 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. Coverage is limited to 90 days annual max.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
$30 copay/PCP visit** $40 copay/ Specialist visit** **Deductible does not apply
50% coinsurance/PCP visit 50% coinsurance/ Specialist visit
Habilitation services
Skilled nursing care
20% coinsurance
50% coinsurance 50% coinsurance
Durable medical equipment 20% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
50% coinsurance/inpatient services 50% coinsurance/outpatient services
Hospice services
None
Children's eye exam Children's glasses
Not covered Not covered
Not covered Not covered Not covered
None None None
If your child needs dental or eye care
Children's dental check-up Not covered
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture
Eye care (Children) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing
Routine eye care (Adult) Routine foot care Weight loss programs
Cosmetic surgery Dental care (Adult) Dental care (Children)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric Surgery (in-network only Surgeon Charges Lifetime max $20,000) Chiropractic care (20 days) Hearing aids ($1,000 maximum per Lifetime) Infertility treatment
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