No out-of-network coverage.
Habilitation services
APN/Aexcel network not
applicable
20%
coinsurance
Not covered No out-of-network coverage.
Skilled nursing care
APN/Aexcel network not
applicable
20%
coinsurance
Not covered
Covers up to 120 days per calendar year.
No out-of-network coverage.
Durable medical
equipment
APN/Aexcel network not
applicable
20%
coinsurance
Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
Your cost if you use an
In-Network Provider
Your cost if
you use an
Out-of-
Network
Provider
Limitations & Exceptions
If you are pregnant
Prenatal and postnatal
care
Prenatal: No charge:
Postnatal: 20%
coinsurance
Prenatal: No charge:
Postnatal: 20% coinsurance if
you are not in an Aexcel or
APN network;
40% coinsurance if you are in
an Aexcel/APN network
Not covered No out-of-network coverage.
Delivery and all
inpatient services
20%
coinsurance
Not covered No out-of-network coverage.
Not covered No out-of-network coverage.
Hospice service
APN/Aexcel network not
applicable
20%
coinsurance
Not covered
Includes inpatient/outpatient coverage
for respite care for 15 days per calendar
year and 5 face to face bereavement
counseling sessions per calendar year.
No out-of-network coverage.
If your child needs dental
or eye care
Eye exam
APN/Aexcel network not
applicable
No charge
Not covered
Covers 1 vision exam per calendar year.
No out-of-network coverage.
Glasses
APN/Aexcel network not
applicable
Not covered
Not covered
Not covered
Dental check-up
APN/Aexcel network not
applicable
Not covered
Not covered
Not covered
If you need help recovering or
have other special health
needs
Home health care
APN/Aexcel network not
applicable
20%
coinsurance
Not covered
Covers up to 240 visits per calendar year
and includes Private Duty Nursing. No
out-of-network coverage.
Rehabilitation services
APN/Aexcel network not
applicable
20%
coinsurance
Not covered
Page 21 of 48