Glasses
Dental check-up
20%
coinsurance
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
20%
coinsurance
20%
coinsurance
20%
coinsurance
20%
coinsurance
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
If you are pregnant
Prenatal and postnatal
care
Prenatal: No charge;
Postnatal: 20%
coinsurance
Delivery and all
inpatient services
20%
coinsurance
If you need help recovering or
have other special health
needs
Home health care
Rehabilitation services
Hospice service
APN/Aexcel network not
applicable
Habilitation services
Skilled nursing care
Durable medical
equipment
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
Your cost if you use an
In-Network Provider
Not covered
Covers 1 vision exam per calendar year.
Not covered
50%
coinsurance
No charge
Not covered
Not covered
If your child needs dental
or eye care
Eye exam
Not covered
Not covered
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
––––––––––– None –––––––––––
Includes inpatient/outpatient coverage
for respite care for 15 days per calendar
year and 5 face to face bereavement
counseling sessions per calendar year.
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
Your cost if
you use an
Out-of-
Network
Provider
––––––––––– None –––––––––––
Covers up to 240 visits per calendar year
and includes Private Duty Nursing (in-
network and out-of-network visits
combined).
––––––––––– None –––––––––––
Covers up to 120 days per calendar year
(in-network and out-of-network visits
combined).
––––––––––– None –––––––––––
––––––––––– None –––––––––––
Limitations & Exceptions
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