health care in apsychiatric hospital. 
Outpatient (group and individual therapy visits):  $15 to  $65 copay 
Cost share may vary depending on where service is provided. 
Skilled nursing facility (SNF) •$0 copay per day for days 1-20 
•$196 copay per day for days 21-100 
•Your plan covers up to 100 days in aSNF 
Physical Therapy  •$15 copay 
ADDITIONAL BENEFITS 
Ambulance $270  copay per date of service 
Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.