What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Non-Participating Provider (You will pay the most)
Services You May Need
Participating Provider (You will pay the least)
Skilled nursing care
20% coinsurance
50% coinsurance
Limited to 60 days per year. Preauthorization required. If you don't get preauthorization, non-participating provider benefits could be reduced by 50% of the total cost of the service. Limited to 1 type of DME (including repair/replacement) every 3 years. Preauthorization required for electric/ motorized scooters or wheelchairs and pneumatic compression devices. If you don't get preauthorization, non- participating provider benefits could be reduced by 50% of the total cost of the service. Bereavement counseling is covered. Limited to 1 exam every 24 months.
Durable medical equipment 20% coinsurance
50% coinsurance
Hospice services
20% coinsurance $15 copay/visit
50% coinsurance 50% coinsurance
If your child needs dental or eye care
Children’s eye exam Children’s glasses
Not Covered Not Covered
Not Covered Not Covered
Not Covered Not Covered
Children’s dental check -up
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 • Bariatric surgery • Cosmetic surgery • Dental care (Adult & Child) • Glasses (Adult & Child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing (except for home health care & hospice) • Routine foot care (except for metabolic or peripheral vascular disease) • 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 • Hearing aids (1 aid per hearing impaired ear every 3 years) • Routine eye care (Adult & Child-1 exam every 24 months)
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