25% 35% Hospice Max: 6 months Max: 6 months Skilled Nursing 25% 35% (Prior authorization is strongly Max: 30 days/year Max: 30 days/year recommended) Miscellaneous Services $40 copay/visit Office visit only If no office visit, Allergy 35% deductible waived, 25% coinsurance Durable Medical Equipment, 25% 35% Prosthetic Appliances & Orthotics Maximum: $200 for Maximum: $200 for (Prior authorization is required for foot orthotics foot orthotics amounts greater than $2,500) Reminder: Deductible applies to all covered services unless otherwise indicated or a applies. Out-of-Network providers can balance bill the difference between their charge and the allowed amount. - 12- In-Network Out-of-Network Medical Plan Service Copay/Coinsurance Coinsurance Miscellaneous Services cont. PKU Supplies (Includes treatment & medical 0% (no deductible) 35% foods) 0% Dietary/Nutritional Counseling (no deductible) 35% (Prior authorization recommended) Max: 8 visits/year
Hospice 25% Max: 6 months 35% Max: 6 months Skilled Nursing (Prior authorization is strongly recommended) 25% Max: 30 days/year 35% Max: 30 days/year Miscellaneous Services Allergy $40 copay/visit Office visit only If no office visit, deductible waived, 25% coinsurance 35% Durable Medical Equipment, Prosthetic Appliances & Orthotics (Prior authorization is required for amounts greater than $2,500) 25% Maximum: $200 for foot orthotics 35% Maximum: $200 for foot orthotics Reminder: Deductible applies to all covered services unless otherwise indicated or a applies. Out-of-Network providers can balance bill the difference between their charge and the allowed amount. - 12- Medical Plan Service In-Network Copay/Coinsurance Out-of-Network Coinsurance Miscellaneous Services cont. PKU Supplies (Includes treatment & medical foods) 0% (no deductible) 35% Dietary/Nutritional Counseling (Prior authorization recommended) 0% (no deductible) Max: 8 visits/year 35%
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