If your child needs dental
or eye care
Eye exam
No charge
20%
coinsurance
Covers 1 vision exam per calendar year.
Glasses
Not covered
Not covered
Not covered
Dental check-up
Not covered
Not covered
Not covered
Common Medical Event Services You May Need
Your cost if you use an In-
Network Provider
Your cost if you use an
Out-of-Network
Provider
Limitations & Exceptions
If you need help recovering or
have other special health
needs
Skilled nursing care
20%
coinsurance
20%
coinsurance
Covers up to 120 days per calendar year
(in-network and out-of-network visits
combined).
Durable medical equipment
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Hospice service
20%
coinsurance
20%
coinsurance
Includes inpatient/outpatient coverage
for respite care for 15 days per calendar
year and 5 face to face bereavement
counseling sessions per calendar year.
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