2020 SBC HRA Plan_Mid-America Apartments_3332254_01.01.2020

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information 50% penalty for failure to precertify inpatient hospice services.

Services You May Need

In-Network Provider (You will pay the least) 20% coinsurance/inpatient; 20% coinsurance/outpatient services

Out-of-Network Provider (You will pay the most) 50% coinsurance/inpatient; 50% coinsurance/outpatient services

Hospice services

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  Private-duty nursing  Routine eye care (Adult)  Routine foot care  Weight loss programs 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  Cosmetic surgery  Dental care (Adult)  Dental care (Children)  Eye care (Children)  Long-term care  Non-emergency care when traveling outside the U.S.

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