Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductibl...
Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits
Dependent Benefits. Dependent means:
