HMO SBCs & Plan Highlights_compressed

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Preauthorization required. 45 days per plan year.

$1,000 co-pay /visit

Not Covered

Skilled nursing care

20% co-insurance

Not Covered

Shoe inserts are not covered.

Durable medical equipment

Limited to 210 days combined Inpatient and Outpatient. One routine eye exam is available every 24 months.

$1,000 co-pay /visit

Not Covered

Hospice services

$50 co-pay /visit

Not Covered

Children’s eye exam

If your child needs dental or eye care

Not Covered

Not Covered

None.

Children’s glasses

Preventive Dental is not covered under your medical benefits.

Not Covered

Not Covered

Children’s dental check-up

108308

SBC-Id :

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