Page 56 - Avatar 2022 Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, & Other
Event (You will pay the Provider (You will Important Information
least) pay the most)
If you need help Home health care 30% coinsurance 50% coinsurance Combined network and out-of-network:
recovering or have 100 visits per benefit period, combined
other special health with visiting nurse.
needs Precertification may be required.
Rehabilitation services 30% coinsurance 50% coinsurance Limit does not apply to Therapy Services
prescribed for the treatment of Mental
Health or Substance Abuse.
Precertification may be required.
Habilitation services Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Skilled nursing care 30% coinsurance 50% coinsurance Combined network and out-of-network:
100 days per benefit period.
Precertification may be required.
Out-of-network: Failure to precertify will
result in benefits payable being reduced
by $250.
Durable medical equipment 30% coinsurance 50% coinsurance Precertification may be required.
Hospice services 30% coinsurance 30% coinsurance Out-of-network: Subject to network
deductible.
Precertification may be required.
If your child needs Children’s eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
dental or eye care Children’s glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

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