Page 7 - 3z.net.18 Employee Benefits

What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Non-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
30 day limit/benefit period for In-
Network Providers. 10 visits/benefit
period for Non-Network Providers.
Mental/behavioral health visits count
towards your substance abuse limit.
Alcoholism treatment (Non-Network)
emergency detoxification - 3 day limit.
Inpatient services 20% coinsurance 40% coinsurance
Residential treatment - 10 days.
Substance Abuse Inpatient (Non-
Network) limited to 1 day. Inpatient
and outpatient substance abuse
rehabilitation programs are limited to 2
episodes per lifetime (In-Network and
Non-Network).
Office visits 20% coinsurance 40% coinsurance
Childbirth/delivery professional Maternity care may include tests and
If you are 20% coinsurance 40% coinsurance
services services described elsewhere in the
pregnant
Childbirth/delivery facility SBC (i.e. ultrasound).
20% coinsurance 40% coinsurance
services
100 visits/benefit period. Limit does
Home health care 20% coinsurance 40% coinsurance
not include I.V. therapy.
$20/visit deductible does
If you need help Rehabilitation services 40% coinsurance
not apply *See Therapy Services section
recovering or have Habilitation services 20% coinsurance 40% coinsurance
other special
Skilled nursing care 20% coinsurance 40% coinsurance 90 day limit/benefit period.
health needs
*See Durable Medical Equipment
Durable medical equipment 20% coinsurance 40% coinsurance
Section
Hospice services No charge No charge --------none--------
$20/visit deductible does
If your child Children’s eye exam not apply 40% coinsurance *See Vision Services section
needs dental or
Children’s glasses Not covered Not covered
eye care
Children’s dental check-up Not covered Not covered *See Dental Services section

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/fi.
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