BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Outpatient Therapy Services Calendar Year Maximum:
90 days for all therapies combined (The limit is not applicable to mental health conditions.)
Note: Outpatient Short Term Rehab copay applies, regardless of place of service, including the home. Outpatient Therapy Services copay
Includes: Physical Therapy Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy
applies, regardless of place of service, including the home.
. Outpatient Cardiac Rehabilitation Calendar Year Maximum: 36 days
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Chiropractic Care Calendar Year Maximum: 20 days Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% after plan deductible
Home Health Care
80% after plan deductible
50% after plan deductible
Calendar Year Maximum: 120 days (includes outpatient private nursing when approved as Medically Necessary) (The limit is not applicable to Mental Health and Substance Use Disorder conditions.) . Hospice Inpatient Services Outpatient Services (same coinsurance level as Home Health Care) Bereavement Counseling Services provided as part of Hospice Care Inpatient
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
Outpatient
80% after plan deductible
50% after plan deductible
Services provided by Mental Health Professional
Covered under Mental Health benefit
Covered under Mental Health benefit
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