What You Will Pay
Out-of-Network Provider (You will pay the most)
Payment of all Out-Of-Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out- Of-Network facility services will
Common Medical Event
Limitations, Exceptions, & Other Important Information
Network Provider (You will pay the least)
Services You May Need
be limited to 175% of the Medicare fee schedule
Pre-notification is recommended for certain Durable medical equipment.
Durable medical equipment
20% coinsurance
40% coinsurance
Hospice services
20% coinsurance
40% coinsurance
Pre-notification is recommended.
No charge, deductible does not apply
Children’s eye exam
40% coinsurance
Applies from birth through age 5.
If your child needs dental or eye care
Children’s glasses
Not covered
Not covered
Not covered.
Children’s dental check-up Not covered
Not covered
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.)
Glasses (Child) Hearing Aids Long Term Care
• • •
Bariatric Surgery Cosmetic Surgery Dental Care (Adult)
Private-duty nursing
• • • •
• • • •
Routine eye care (Adult)
Routine Foot Care
• Non-emergency care when traveling outside the U.S.
Dental check-ups (Child)
Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic Care (limited to 30 visits per calendar year) •
Infertility treatment (except promotion of conception)
Acupuncture
•
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
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