BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Routine Foot Disorders
Not covered except for services associated with foot care for diabetes, peripheral neuropathies and peripheral vascular disease when Medically Necessary.
Not covered except for services associated with foot care for diabetes, peripheral neuropathies and peripheral vascular disease when Medically Necessary.
Mental Health Inpatient
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
Includes Acute Inpatient and Residential Treatment Calendar Year Maximum: Unlimited
Outpatient
Outpatient - Office Visits Includes individual, family and group psychotherapy; medication management, virtual care, etc. Calendar Year Maximum: Unlimited Dedicated Virtual Providers MDLIVE Behavioral Services Outpatient - All Other Services Includes Partial Hospitalization, Intensive Outpatient Services, virtual care, etc. Applied Behavior Analysis Transcranial Magnetic
No charge after the $30 per visit copay
50% of the Maximum Reimbursable Charge after plan deductible
No charge after the $20 per visit copay
In-Network coverage only
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
Stimulation (TMS), etc. Calendar Year Maximum: Unlimited
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