What You Will Pay
Tier III (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 be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
$25 copay/visit, deductible does not apply $25 copay/visit, deductible does not apply
$25 copay/visit, deductible does not apply $25 copay/visit, deductible does not apply
Physical and occupational therapy: limited to a combined maximum of 30 visits of office and outpatient facility services per calendar year. Speech therapy: limited to 30 visit maximum per calendar year.
Rehabilitation services
40% coinsurance
Habilitation services
40% coinsurance
Skilled nursing care 20% coinsurance
20% coinsurance 40% coinsurance
30 visits/calendar year
Durable medical equipment
Pre-notification is recommended for certain Durable medical equipment.
20% coinsurance
20% coinsurance 40% coinsurance
No charge, deductible does not apply No charge, deductible does not apply
No charge, deductible does not apply No charge, deductible does not apply
Hospice services
40% coinsurance
Pre-notification is recommended.
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
Not covered.
Children’s dental check-up
Not covered
Not covered
Not covered
Not covered.
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