4 visits 35% Outpatient Services $0 copay then $25 copay/visit Rehabilitative Services Physical, Occupational, Cardiac, Respiratory, Pulmonary & Speech Therapy, Acupuncture, Chiropractic Note: Naturopathic is now included under Primary Care Physician Visit Inpatient Services 25% 35% (Pre-certification is strongly Maximum of 30 Maximum of 30 recommended) days/year days/year 35% Max: 30 visits/year (this is a combined maximum of 30 visits for all rehab services) Note: Currently there $25 copay/visit is no network Maximum of 30 for Acupuncture, so visits/year Outpatient Services out-of-network (this is a combined is the same as maximum of 30 visits but the for all rehab services) member will be balance billed the difference between the allowed amount and provider charge. -11 – In-Network Out-of-Network Medical Plan Services Coinsurance Extended Care Services Home Health Care (Prior authorization is strongly $25 copay/visit 35% recommended) Max: 30 visits/year Max: 30 visits/year
Outpatient Services 4 visits $0 copay then $25 copay/visit 35% Rehabilitative Services Physical, Occupational, Cardiac, Respiratory, Pulmonary & Speech Therapy, Acupuncture, Chiropractic Note: Naturopathic is now included under Primary Care Physician Visit Inpatient Services (Pre-certification is strongly recommended) 25% Maximum of 30 days/year 35% Maximum of 30 days/year Outpatient Services $25 copay/visit Maximum of 30 visits/year (this is a combined maximum of 30 visits for all rehab services) 35% Max: 30 visits/year (this is a combined maximum of 30 visits for all rehab services) Note: Currently there is no network for Acupuncture, so out-of-network is the same as but the member will be balance billed the difference between the allowed amount and provider charge. -11 – Medical Plan Services In-Network Out-of-Network Coinsurance Extended Care Services Home Health Care (Prior authorization is strongly recommended) $25 copay/visit Max: 30 visits/year 35% Max: 30 visits/year