Page 120 - Tampa Bay Rays 2022 Flipbook

What You Will Pay

Common Medical Services You May Need Out-of-Network Limitations, Exceptions, & Other
Event Network Provider (You Important Information
will pay the least) Provider (You will pay
the most)
If you need help Home health care 30% coinsurance 50% coinsurance Combined network and out-of-network: 100
recovering or have visits per benefit period, combined with
other special health visiting nurse.
needs Precertification may be required.
Rehabilitation services 30% coinsurance 50% coinsurance Combined network and out-of-network: 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 30% coinsurance 50% coinsurance Combined network and out-of-network: 100
days per benefit period.
Precertification may be required.
Out-of-network: Failure to precertify will
result in benefits payable being reduced by
$250.
Durable medical equipment 30% coinsurance 50% coinsurance Precertification may be required.
Hospice services 30% coinsurance 30% coinsurance Out-of-network: Subject to network
deductible.
Precertification may be required.
If your child needs Children’s eye exam Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
dental or eye care Children’s glasses Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−
Children’s dental check-up Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−−

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