Page 107 - Trident 2022 Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, and Other
Event (You will pay the Provider (You will Important Information

If you need help Home health care least) pay the most) Combined network and out-of-network:
recovering or have 100 visits per benefit period, combined
other special health Rehabilitation services 30% coinsurance 50% coinsurance with visiting nurse.
needs Habilitation services Precertification may be required.
Skilled nursing care Precertification may be required.
30% coinsurance 50% coinsurance ----------------------None-------------------
Not covered Not covered Combined network and out-of-network:
30% coinsurance 50% coinsurance 100 days per benefit period.
Precertification may be required.
Durable medical equipment 30% coinsurance 50% coinsurance Out-of-network: Failure to precertify will
Hospice service 30% coinsurance 30% coinsurance result in benefits payable being reduced
by $250.
If your child needs Children’s Eye exam Not covered Not covered Precertification may be required.
dental or eye care Children’s Glasses Not covered Not covered Out-of-network: Subject to network
Children’s Dental check-up Not covered Not covered deductible.
Precertification may be required.
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