BCN (Retiree Faculty and Staff version) - MSU Human Resources

CommonMedical EventIf you need helprecovering orhave otherspecial healthneedsServices You May NeedHome health careRehabilitation servicesHabilitation servicesSkilled nursing careDurable medical equipmentHospice serviceYour cost if you use aIn-Network Out-of-NetworkProviderProviderNo Charge after 20% co-insurance afterdeductibledeductible$20 Co-pay per visit 20% co-insurance afterdeductibleNot Covered Not Covered ---none---No Charge afterdeductible20% co-insurance afterdeductibleNo Charge afterdeductible20% co-insurance afterdeductibleNot coveredNo charge afterdeductibleLimitations & ExceptionsCombined in and out of network benefitslimited to 60 days per calendar year. Priorauthorization may be required out of network.Combined in and out of network benefitslimited to 60 days per calendar year. Priorauthorization may be requiredLimited to a maximum of 100 days perbenefit period. Prior authorization required.Prior authorization may be required/breastpump covered in full when authorized andobtained from Participating supplier.. Prior authorization required.If your childneeds dental oreye careEye examGlassesDental check-upNot Covered Not Covered ---none---Not Covered Not Covered ---none---Not Covered Not Covered ---none---4 of 8