Not covered No out-of-network coverage.
Habilitation services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Skilled nursing care
20%
coinsurance
40%
coinsurance
Not covered
Covers up to 120 days per calendar year.
No out-of-network coverage.
Durable medical
equipment
20%
coinsurance
40%
coinsurance
Common Medical Event
Services You May
Need
Your cost if you use
a Banner Health
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: 40%
coinsurance
Not covered No out-of-network coverage.
Delivery and all
inpatient services
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Not covered No out-of-network coverage.
Hospice service
20%
coinsurance
40%
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
No charge
No charge
Not covered
Covers 1 vision exam per calendar year.
No out-of-network coverage.
Glasses
Not covered
Not covered
Not covered
Not covered
Dental check-up
Not covered
Not covered
Not covered
Not covered
If you need help recovering or
have other special health
needs
Home health care
20%
coinsurance
40%
coinsurance
Not covered
Covers up to 240 visits per calendar year
and includes Private Duty Nursing. No
out-of-network coverage.
Rehabilitation services
20%
coinsurance
40%
coinsurance
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