Page 15 - 3z.20 Employee Benefits

Common What You Will Pay Limitations, Exceptions, &
Medical Event Services You May Need Network Provider Out-of-Network Provider Other Important Information
(You will pay the least) (You will pay the most)
occupational therapy, pulmonary
rehabilitation therapy, cardiac
rehabilitation therapy, post-
cochlear implant aural therapy,
and cognitive rehabilitation
therapy.
60 visits/year. Prior Authorization
is required. If you don't get Prior
Skilled nursing care coinsurance coinsurance 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
Durable medical equipment coinsurance coinsurance 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,
Hospice services coinsurance coinsurance benefits could be reduced by
50% of the total cost of the
service.
Children’s eye exam Not covered Not covered
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

* For more information about limitations and exceptions, see the plan or policy document at www.myallsavers.com. 5 of 8