Page 81 - 2022 Washington Nationals Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, and Other
Event (You will pay the Provider (You will Important Information

If you need help Home health care least) pay the most) Out-of-network: Subject to network
recovering or have Rehabilitation services deductible.
other special health 20% coinsurance 20% coinsurance Precertification may be required.
needs Combined network and out-of-network:
$15 copay/visit 40% coinsurance 70 combined physical medicine, speech,
and occupational therapy visits and per
Habilitation services Not covered Not covered benefit period.
Skilled nursing care 20% coinsurance 40% coinsurance Precertification may be required.
−−−−−−−−−−−none−−−−−−−−−−−
If your child needs Durable medical equipment 20% coinsurance 40% coinsurance Out-of-network: 100 days per benefit
dental or eye care Hospice service 20% coinsurance 40% coinsurance period.
Precertification may be required.
Children’s Eye exam Not covered Not covered Precertification may be required.
Children’s Glasses Not covered Not covered Precertification may be required.
Children’s Dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
−−−−−−−−−−−none−−−−−−−−−−−
−−−−−−−−−−−none−−−−−−−−−−−

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