Page 19 - PWH.19 Employee Benefits

What You Will Pay Limitations, Exceptions, & Other
vider Non-Network Provider Important Information
least) (You will pay the most)
ce 0% coinsurance --------none--------

ce 30% coinsurance *See Vision Services section
Not covered *See Dental Services section
Not covered

plan document for more information and a list of any other excluded

nless you have been Bariatric surgery
etes. Dental Check-up
Infertility treatment
Weight loss programs

isn’t a complete list. Please see your plan document.)

ided outside the United Private-duty nursing $50,000
bsglobalcore.com maximum/benefit period. $100,000
maximum/lifetime.

want to continue your coverage after it ends. The contact information for those
- Suite 300, Columbus, Ohio 43215, (800) 686-1526, (614) 644-2673.
-EBSA (3272), www.dol.gov/ebsa/healthreform. Other coverage options may be
he Health Insurance Marketplace. For more information about the Marketplace,

u have a complaint against your plan for a denial of a claim. This complaint is
the explanation of benefits you will receive for that medical claim. Your plan
grievance for any reason to your plan. For more information about your rights,

-EBSA (3272), www.dol.gov/ebsa/healthreform
Columbus, Ohio 43215, (800) 686-1526, (614) 644-2673

document at https://eoc.anthem.com/eocdps/fi.

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