What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). 50% penalty for no out-of-network 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.) Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. 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.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
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
If you need help recovering or have other special health needs
Rehabilitation services
$30 copay/PCP visit** $40 copay/ Specialist visit** **Deductible does not apply
50% coinsurance/PCP visit 50% coinsurance/ Specialist visit
Habilitation services
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