Page 27 - QCS.19 Employee Benefits

What You Will Pay Limitations, Exceptions, &

ider Out-of-Network Provider Other Important Information

least) (You will pay the most) and services described
elsewhere in the SBC (i.e.
50% coinsurance ultrasound). Prior Authorization is
50% coinsurance required for inpatient services. If
50% coinsurance you don't get Prior Authorization,
benefits could be reduced by
50% coinsurance 50% of the total cost of the
service.
50% coinsurance
30 visits/year. Prior Authorization
50% coinsurance is required. If you don't get Prior
Not covered Authorization, benefits could be
Not covered reduced by 50% of the total cost
Not covered of the service.
30 visits/year. Includes physical
therapy, speech therapy, and
occupational therapy.
60 visits/year. Prior Authorization
is required. If you don't get Prior
Authorization, benefits could be
reduced by 50% of the total cost
of the service.
Prior Authorization is required if
greater than $1000. If you don't
get Prior Authorization, benefits
could be reduced by 50% of the
total cost of the service.
Prior Authorization is required. If
you don't get Prior Authorization,
benefits could be reduced by
50% of the total cost of the
service.

None

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