Page 112 - Tampa Bay Rays 2022 Flipbook

What You Will Pay
Common Limitations, Exceptions, & Other
Medical Event Services You May Need Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need Home health care 20% coinsurance 20% coinsurance Out-of-network: Subject to network
help recovering deductible.
or have other Precertification may be required.
special health Rehabilitation services $15 copay/visit 40% coinsurance Combined network and out-of-network:
needs Deductible does not apply. 70 combined physical medicine,
occupational therapy, and speech
therapy visits per benefit period.
Precertification may be required.
Habilitation services Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Skilled nursing care 20% coinsurance 40% coinsurance Out-of-network: 100 days per benefit
period.
Precertification may be required.
Durable medical equipment 20% coinsurance 40% coinsurance Precertification may be required.
Hospice services 20% coinsurance 40% coinsurance Precertification may be required.
If your child Children’s eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
needs dental or Children’s glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
eye care Children’s dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

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