other special health 30 visits Spinal Manipulation; 20 visits needs each Physical Therapy, Occupational Therapy, Cognitive Rehab Therapy, & 20% Coinsurance 40% Coinsurance Speech Therapy; 36 visits for Cardiac Rehab, 20 visits for Pulmonary Rehab. Visits are combined In & Out of Network per plan year. Not Covered Not Covered None Prior Authorization required 20% Coinsurance 40% Coinsurance 60 day limit per plan year combined Network & Non-Network. Prior Authorization required for DME devices that cost 20% Coinsurance 40% Coinsurance more than $1,000 per device (Purchase or cumulative rental). Prior Authorization required Inpatient 20% Coinsurance 40% Coinsurance non-network. Not Covered Not Covered None Children’s eye exam If your child needs Not Covered Not Covered None Children’s glasses dental or eye care Children’s dental Not Covered Not Covered None Excluded Services & Covered Services: Services Your Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other .) Acupuncture Cosmetic Surgery Non-emergency care when traveling outside the U.S. Adult routine vision exam (i.e. refraction) Dental Care Private-duty nursing Child dental check-up Habilitation services Weight loss programs routine vision exam (i.e. refraction) Infertility treatment Acupuncture Child vision glasses Long-term care Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your document.) Bariatric Surgery Hearing aids Routine foot care
other special health needs 20% Coinsurance 40% Coinsurance 30 visits Spinal Manipulation; 20 visits each Physical Therapy, Occupational Therapy, Cognitive Rehab Therapy, & Speech Therapy; 36 visits for Cardiac Rehab, 20 visits for Pulmonary Rehab. Visits are combined In & Out of Network per plan year. Not Covered Not Covered None 20% Coinsurance 40% Coinsurance Prior Authorization required 60 day limit per plan year combined Network & Non-Network. 20% Coinsurance 40% Coinsurance Prior Authorization required for DME devices that cost more than $1,000 per device (Purchase or cumulative rental). 20% Coinsurance 40% Coinsurance Prior Authorization required Inpatient non-network. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered None Children’s dental Not Covered Not Covered None Excluded Services & Covered Services: Services Your Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other .) Acupuncture Adult routine vision exam (i.e. refraction) Child dental check-up routine vision exam (i.e. refraction) Child vision glasses Cosmetic Surgery Dental Care Habilitation services Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Weight loss programs Acupuncture Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your document.) Bariatric Surgery Hearing aids Routine foot care
RegularStateofNE2018SBC.docx