What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 50% penalty for failure to precertify out-of-network speech therapy services. 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. 50% penalty for no out-of-network precertification. Coverage is limited to 90 days annual max. 50% penalty for no out-of-network precertification. 50% penalty for failure to precertify out-of-network inpatient hospice services.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Habilitation services
20% coinsurance/visit
50% coinsurance/visit
Skilled nursing care
20% coinsurance
50% coinsurance
Durable medical equipment 20% coinsurance
50% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
50% coinsurance/inpatient services 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
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