Your cost if you use a Common Medical Event Services You May Need Limitations & Exceptions Preferred Non-Preferred Home health care $0 copayment 20% coinsurance None $0 copayment- 20% coinsurance- Consult your policy for more 36 visits per 36 visits per Rehabilitation services detailed service limitations. benefit period benefit period combined PT, combined PT, OT, ST OT, ST No coverage is provided for If you need help recovering or have Habilitation services Not covered Not covered habilitation services. other special health needs Consult your policy for more Skilled nursing care 0% coinsurance 20% coinsurance detailed service limitations. Durable medical equipment 0% coinsurance 20% coinsurance None Consult your policy for more Hospice service 0% coinsurance 20% coinsurance detailed service limitations.
Common Medical Event Services You May Need Your cost if you use a Limitations & Exceptions Preferred Non-Preferred If you need help recovering or have other special health needs Home health care $0 copayment 20% coinsurance None Rehabilitation services $0 copayment- 36 visits per benefit period combined PT, OT, ST 20% coinsurance- 36 visits per benefit period combined PT, OT, ST Consult your policy for more detailed service limitations. Habilitation services Not covered Not covered No coverage is provided for habilitation services. Skilled nursing care 0% coinsurance 20% coinsurance Consult your policy for more detailed service limitations. Durable medical equipment 0% coinsurance 20% coinsurance None Hospice service 0% coinsurance 20% coinsurance Consult your policy for more detailed service limitations.
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