•Eyeglass lens options may be available with the maximum benefit  
coverage amount up to 1pair per year. 
•Maximum benefit coverage amount is limited to one time use per  
year. 
MENTAL HEALTH SERVICES 
Inpatient 
Your plan covers up to 190 days 
in alifetime for inpatient mental 
health care in apsychiatric 
hospital $0 copay 
Outpatient group and individual 
therapy visits $0 copay 
SKILLED NURSING FACILITY (SNF) 
Your plan covers up to 100 days 
in aSNF $0 copay 
PHYSICAL THERAPY