Page 68 - 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)

Office visits No charge 30% coinsurance Depending on the type of services, a

Childbirth/delivery No charge 30% coinsurance copayment, coinsurance or deductible

If you are pregnant professional services may apply. Maternity care may
include tests and services described
Childbirth/delivery facility No charge 30% coinsurance elsewhere in the SBC (i.e.
services
ultrasound).

$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
an annual max of 20 visits for Physical
No charge/visit for Physical, 30% coinsurance/visit for

Speech, Hearing & Physical, Speech, Hearing & therapy and 20 visits for Speech,
Hearing & Occupational therapy and
If you need help Rehabilitation services Occupational therapy Occupational therapy 20 visits annual max for Chiropractic

recovering or have other care services.
special health needs No charge/visit for Chiropractic 30% coinsurance/visit for
care services 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
or eye care Children's glasses Not covered None
Children's dental check-up Not covered Not covered None

4 of 7