Page 103 - QCS.19 SPD - PPO
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What You Will Pay
 Common                                            Limitations, Exceptions, & Other
 Services You May Need  Network Provider  Out-of-Network Provider
 Medical Event                                           Important Information
 (You will pay the least)  (You will pay the most)

 Hospice service  0% coinsurance  50% coinsurance  Prior Authorization is required. If you don't

                                              get Prior Authorization, benefits could be

                                              reduced by 50% of the total cost of the
                                              service.

 Children's eye exam  Not Covered  Not Covered  None
 If your child needs
 Children's glasses  Not Covered  Not Covered  None
 dental or eye care
 Children's dental check-up  Not Covered  Not Covered  None


 Excluded Services & Other Covered Services:

 Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

 ·  Acupuncture  ·  Long-term care
 ·  Bariatric surgery  ·  Non-emergency care when traveling outside the  ·  Routine eye care (adult)

 ·  Cosmetic surgery  United States  ·  Routine foot care, and

 ·  Dental care (adult)  ·  Private-duty nursing  ·  Weight-loss programs

 ·  Infertility treatment

 Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

 ·  Chiropractic care

 ·  Hearing aids




































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