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
No charge after the $30 PCP or $40 Specialist per office visit copay
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
No charge after the $30 PCP or $40 Specialist per office visit copay
80% after plan deductible
No charge
Inpatient Facility
80% after plan deductible
Outpatient Facility
80% after plan deductible
Outpatient Therapy Services Calendar Year Maximum:
No charge after the $30 PCP or $40 Specialist per office visit copay Note: Outpatient Therapy Services copay applies, regardless of place of service, including the home. The Outpatient Therapy Services copay does not apply to services provided as part of a Home Health Care Services visit.
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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