Page 46 - 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)

$250 penalty for no precertification.
Coverage is limited to 60 visits annual

Home health care No charge 30% coinsurance max. (The limit is not applicable to
mental health and substance use
disorder conditions.)

$250 penalty for failure to precertify
speech therapy. Coverage is limited to

$50 copay/visit for Physical, an annual max of 20 visits for Physical
Speech, Hearing & 30% coinsurance/visit for therapy and 20 visits for Speech,
Occupational therapy** Physical, Speech, Hearing & Hearing & Occupational therapy and
If you need help Rehabilitation services Occupational therapy 20 visits annual max for Chiropractic
recovering or have other $50 copay/visit for Chiropractic care services.

special health needs care** 30% coinsurance/visit for

**Deductible does not apply Chiropractic care Limits are not applicable to mental
health conditions for Physical, Speech

and Occupational therapies.
Habilitation services Not covered Not covered None

$250 penalty for no precertification.
Skilled nursing care No charge 30% coinsurance Coverage is limited to 60 days annual
max.

Durable medical equipment No charge 30% coinsurance $250 penalty for no precertification.

Hospice services No charge 30% coinsurance $250 penalty for no precertification.
Children's eye exam Not covered None
If your child needs dental Children's glasses Not covered None
or eye care
Children's dental check-up Not covered Not covered None

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