Your Cost If Your Cost Common You Use a If You Use Services You May Need Limitations & Exceptions Medical Event Network an Provider Pre-authorization required for Home health care 0% coinsurance 40% coinsurance after Provider care. calendar year deductible Rehabilitation services $25 copay per visit 40% coinsurance after None ––––––––––– ––––––––––– calendar year deductible If you need help recovering or have Habilitation services $25 copay per visit 40% coinsurance after Benefit limitations may apply. calendar year deductible other special health needs Skilled nursing care 0% coinsurance 40% coinsurance after Coverage is limited to 100 days per calendar year. Pre-authorization required calendar year deductible for out-of-network care. Durable medical equipment 0% coinsurance 40% coinsurance after None ––––––––––– ––––––––––– calendar year deductible Hospice service 0% coinsurance 40% coinsurance after Pre-authorization required for care. calendar year deductible Eye exam No charge 40% coinsurance after Coverage is limited to 1 routine eye exam per calendar year. If your child calendar year deductible needs dental or Glasses Not covered Not covered Not covered. eye care Dental Not covered Not covered Not covered. Excluded Services & Other Covered Services: (This isn't a complete list. Check your policy or plan document for other Services Your Plan Does NOT Cover excluded services.) Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult & Child) Non-emergency care when traveling outside the Routine foot care Glasses (Child) U.S. Weight loss programs (This isn't a complete list. your policy or plan document for other covered services and your costs for these services.) Other Covered Services Acupuncture Hearing aids - Coverage is limited to 1 hearing aid Infertility treatment - Benefit limitations may apply. to a maximum of $1,400 per 36 months up to age Routine eye care (Adult) - Coverage is limited to 1 Bariatric surgery 19. routine eye exam per calendar year. Chiropractic care
Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Provider Limitations & Exceptions If you need help recovering or have other special health needs Home health care 0% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Rehabilitation services $25 copay per visit 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Habilitation services $25 copay per visit 40% coinsurance after calendar year deductible Benefit limitations may apply. Skilled nursing care 0% coinsurance 40% coinsurance after calendar year deductible Coverage is limited to 100 days per calendar year. Pre-authorization required for out-of-network care. Durable medical equipment 0% coinsurance 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Hospice service 0% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. If your child needs dental or eye care Eye exam No charge 40% coinsurance after calendar year deductible Coverage is limited to 1 routine eye exam per calendar year. Glasses Not covered Not covered Not covered. Dental Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult & Child) Non-emergency care when traveling outside the Routine foot care Glasses (Child) U.S. Weight loss programs Other Covered Services (This isn't a complete list. your policy or plan document for other covered services and your costs for these services.) Acupuncture Hearing aids - Coverage is limited to 1 hearing aid Infertility treatment - Benefit limitations may apply. Bariatric surgery to a maximum of $1,400 per 36 months up to age Routine eye care (Adult) - Coverage is limited to 1 Chiropractic care 19. routine eye exam per calendar year.
SBC%20In%20State%20Plan%20Eff%202016%2001%2001%20FINAL.docx