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)
participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Baby does not count toward the mother’s expense; therefore the family deductible amount may apply. Limited to 60 visits 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. Physical, occupational, cognitive, respiratory/pulmonary therapy limited to 20 visits per each type of therapy per year. Post-cochlear implant aural therapy limited to 30 visits per year. Cardia rehab limited to 36 visits per year.
If you need help recovering or have other special health needs
Home health care
20% coinsurance
50% coinsurance
Rehabilitation services
20% coinsurance
50% coinsurance
Habilitation services Skilled nursing care
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
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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
50% coinsurance 50% coinsurance
Children’s eye exam
No Charge
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