Page 43 - Benefits Book Tanner Manor 2020
P. 43
Limitations, Exceptions & Other Important Information
3ODQ Document for ŚȱȱŜ
&RSD\ applies to exam charge only. See other services. None None 3UHDXWKRUL]DWLRQ is required. If not received, a penalty will be applied. Limited to 30 visits per year. 3UHDXWKRUL]DWLRQ is required for Inpatient. If not received, a penalty will be applied. Inpatient limited to 31 days per year. Outpatient limited to 30 visits per year. 3UHDXWKRUL]DWLRQ is required. If not received, a penalty will be applied. 3UHDXWKRUL]DWLRQ is required for amounts greater th
What You Will Pay SODQ document for more information and a list of any other
FRSD\/visit, then covered at 100% • Non-emergency care when traveling outside the U.S.
$60 FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRLQVXUDQFH 30% Not covered Not covered Not covered 3ODQ Generally Does NOT Cover (Check your policy or • Hearing aids • Infertility treatment • Long-term care
Services You May Need Office visits Childbirth/delivery professional services Childbirth/delivery facility services +RPH KHDOWK FDUH 5HKDELOLWDWLRQ VHUYLFHV +DELOLWDWLRQ VHUYLFHV 6NLOOHG QXUVLQJ FDUH 'XUDEOH PHGLFDO HTXLSPHQW +RVSLFH VHUYLFHV Children's eye exam Children's glasses Children's dental checkup Excluded Services & Other Covered Services:
Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services Your • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult)
