If you need Office Visit Office Office mental health, $25/visit Not covered --------none-------- Outpatient services behavioral health, Other Outpatient Outpatient Other Outpatient or substance 15% coinsurance Not covered --------none-------- abuse services Inpatient services 15% coinsurance Not covered Pre-authorization required $25/visit first 1 visit then Office visits Not covered 15% coinsurance Maternity care may include tests and If you are Childbirth/delivery professional services described elsewhere in the No charge Not covered pregnant services SBC (i.e. ultrasound). Childbirth/delivery facility 15% coinsurance Not covered services 120 visits/benefit period for Home health care 15% coinsurance Not covered Providers including private duty nursing. 60 visits for Physical, Occupational and Speech Therapy Rehabilitation services $35/visit Not covered combined/benefit period for Providers. If you need help 60 visits for Physical, Occupational recovering or have other special and Speech Therapy health needs Habilitation services $35/visit Not covered combined/benefit period for Providers. Habilitation visits count towards your rehabilitation limit. 120 days limit/benefit period for Skilled nursing care 15% coinsurance Not covered Providers. Durable medical equipment 15% coinsurance Not covered --------none-------- Hospice services 15% coinsurance Not covered --------none-------- Children’s eye exam No charge Not covered --------none-------- If your child needs dental or Children’s glasses Not covered Not covered --------none-------- eye care Children’s dental Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other .)
If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit $25/visit Other Outpatient 15% coinsurance Office Not covered Outpatient Not covered Office --------none-------- Other Outpatient --------none-------- Inpatient services 15% coinsurance Not covered Pre-authorization required If you are pregnant Office visits $25/visit first 1 visit then 15% coinsurance Not covered Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge Not covered Childbirth/delivery facility services 15% coinsurance Not covered If you need help recovering or have other special health needs Home health care 15% coinsurance Not covered 120 visits/benefit period for Providers including private duty nursing. Rehabilitation services $35/visit Not covered 60 visits for Physical, Occupational and Speech Therapy combined/benefit period for Providers. Habilitation services $35/visit Not covered 60 visits for Physical, Occupational and Speech Therapy combined/benefit period for Providers. Habilitation visits count towards your rehabilitation limit. Skilled nursing care 15% coinsurance Not covered 120 days limit/benefit period for Providers. Durable medical equipment 15% coinsurance Not covered --------none-------- Hospice services 15% coinsurance Not covered --------none-------- If your child needs dental or eye care Children’s eye exam No charge Not covered --------none-------- Children’s glasses Not covered Not covered --------none-------- Children’s dental Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other .)
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