exclusions. 
MENTAL HEALTH SERVICES 
Inpatient 
Your plan covers up to 190 days 
in alifetime for inpatient mental 
health care in apsychiatric 
hospital $750 copay per admit 30% of the cost 
Outpatient group and individual 
therapy visits 
Cost share may vary depending 
on where service is provided. $40 to  $90 copay 30% of the cost 
SKILLED NURSING FACILITY (SNF) 
Your plan covers up to 100 days 
in aSNF $0 copay per day for days 1-20 
$188 copay per day for days