Page 22 - Benefits Summary 2018-2019

What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other
Medical Event In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)

Coverage is limited to 60 visits annual
max. (The limit is not applicable to
Home health care 30% coinsurance Not covered
mental health and substance use
disorder conditions.)

Coverage is limited to an annual max
of 20 visits for Physical therapy and
$50 copay/visit for Physical, 20 visits for Speech, Hearing &

Speech, Hearing & Occupational Occupational therapy and 20 visits
therapy**
If you need help Rehabilitation services Not covered annual max for Chiropractic care

recovering or have other $50 copay/visit for Chiropractic services.
special health needs care**

**Deductible does not apply Limits are not applicable to mental
health conditions for Physical, Speech
and Occupational therapies.
Habilitation services Not covered Not covered None

Coverage is limited to 60 days annual
Skilled nursing care 30% coinsurance Not covered
max.

Durable medical equipment 30% coinsurance Not covered None
Hospice services 30% coinsurance Not covered None

Children's eye exam Not covered Not covered None
If your child needs dental Children's glasses Not covered Not covered None

or eye care
Children's dental check-up Not covered Not covered None

5 of 8