What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 50% penalty for no precertification. Coverage is limited to 120 days annual max. 16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.) 50% penalty for failure to precertify speech therapy services. Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days annual max for Chiropractic care services Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. 50% penalty for failure to precertify speech therapy services. Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. 50% penalty for no precertification. Coverage is limited to 90 days annual max. 50% penalty for no precertification.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Home health care
20% coinsurance
50% coinsurance
$30 copay/PCP visit** $40 copay/Specialist visit** **Deductible does not apply
50% coinsurance/PCP visit 50% coinsurance/Specialist visit
Rehabilitation services
If you need help recovering or have other special health needs
$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
Durable medical equipment 20% coinsurance
50% coinsurance
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