120 visits/calendar year. Penalty of $400 per 0% 20% occurrence for failure to obtain for out-of-network care. $15 /visit, doesn't 20% 60 visits/calendar year for Physical, Occupational apply & Speech Therapy combined. Includes treatment $15 /visit, doesn't If you need help of Autism. 20% apply recovering or have other special 90 days/calendar year. Penalty of $400 per $100 /stay, doesn't health needs 20% occurrence for failure to obtain for out-of-network apply care. Limited to 1 for same/similar purpose. Excludes No charge 20% repairs for misuse/abuse. Penalty of $400 per occurrence for failure to 0% 20% obtain for out-of-network care. Children's eye exam Not covered Not covered Not covered. If your child needs Children's glasses Not covered Not covered Not covered. dental or eye care Children's dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Generally Does NOT Cover (Check your policy or document for more information and a list of any other .) Acupuncture Glasses (Child) Routine eye care (Adult & Child) Bariatric surgery Long-term care Routine foot care Cosmetic surgery Non-emergency care when traveling outside Weight loss programs - Except for required preventive the U.S. services. Dental care (Adult & Child)
If you need help recovering or have other special health needs 0% 20% 120 visits/calendar year. Penalty of $400 per occurrence for failure to obtain for out-of-network care. $15 /visit, doesn't apply 20% 60 visits/calendar year for Physical, Occupational & Speech Therapy combined. Includes treatment of Autism. $15 /visit, doesn't apply 20% $100 /stay, doesn't apply 20% 90 days/calendar year. Penalty of $400 per occurrence for failure to obtain for out-of-network care. No charge 20% Limited to 1 for same/similar purpose. Excludes repairs for misuse/abuse. 0% 20% Penalty of $400 per occurrence for failure to obtain for out-of-network care. If your child needs dental or eye care Children's eye exam Not covered Not covered Not covered. Children's glasses Not covered Not covered Not covered. Children's dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Generally Does NOT Cover (Check your policy or document for more information and a list of any other .) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult & Child) Glasses (Child) Long-term care Non-emergency care when traveling outside the U.S. Routine eye care (Adult & Child) Routine foot care Weight loss programs - Except for required preventive services.
summary%20of%20benefits%20and%20coverages.docx