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Network Provider What You Will Pay Exceptions, & Limitations, Out-of-Network Provider Other Important Information (You will pay the most) (You will pay the least) is required. If Prior Authorization you don't get Prior Authorization, benefits could be reduced by coinsurance coinsurance 50% 50% of the total cost of the service. Not covered Not covered Not covered Not covered None Not covered Not covered Does NOT Cover (This isn’
Services You May Need 0% Hospice services Children’s eye exam Children’s glasses Children’s dental check- up Does this plan provide Minimum Essential Coverage? Yes.
Common Medical Event If your child needs dental or eye care Excluded Services & Other Covered Services: Services Your Plan Bariatric surgery x Cosmetic surgery x Dental care (adult) x Infertility treatment x Acupuncture x Chiropractic care, and x www.HealthCare.gov or call 1-800-318-2596. www.dol.gov/ebsa/healthreform.
