BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities Calendar Year Maximum: 90 days combined Laboratory Services Laboratory Services in a Physician’s Office Visit Laboratory Services in an Outpatient Hospital Facility
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
Laboratory Services in an Independent Lab Facility
80% after plan deductible
Radiology Services Radiology Services in a Physician’s Office Visit Radiology Services in an Outpatient Hospital Facility Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans and PET Scans) Physician’s Office Visit
80% after plan deductible
80% after plan deductible
80% after plan deductible
Inpatient Facility
80% after plan deductible
80% after plan deductible
Outpatient Facility
Outpatient Therapy Services Calendar Year Maximum:
80% after plan deductible
90 days for all therapies combined (The limit is not applicable to mental health conditions.) Includes:
Physical Therapy Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy
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