| If you are pregnant |
Office visits |
No charge |
50% coinsurance |
Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Childbirth/delivery professional services |
No charge after deductible |
50% coinsurance |
None |
| Childbirth/delivery facility services |
No charge after deductible |
50% coinsurance |
None |
| If you need help recovering or have other special health needs |
Home health care |
No charge after deductible |
50% coinsurance |
(100 visits per benefit period) |
| Rehabilitation services (Physical Therapy) |
No charge after deductible |
50% coinsurance |
(20 visits per benefit period) |
| Habilitation services (Occupational Therapy) |
No charge after deductible |
50% coinsurance |
(20 visits per benefit period) |
| Habilitation services (Speech Therapy) |
No charge after deductible |
50% coinsurance |
(20 visits per benefit period) |
| Skilled nursing care |
No charge after deductible |
50% coinsurance |
(90 days per benefit period) |
| Durable medical equipment |
No charge after deductible |
50% coinsurance |
None |
| Hospice services |
No charge after deductible |
50% coinsurance |
None |
| If your child needs dental or eye care |
Children's eye exam |
No charge |
50% coinsurance |
None |
| Children's glasses |
Not Covered |
Excluded Service |
| Children's dental check-up |
Not Covered |
Excluded Service |