Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
Outpatient group and individual 
therapy visits 
Cost share may vary depending 
on where service is provided. $30 to  $80 copay $30 to  $80 copay 
SKILLED NURSING FACILITY (SNF) 
Your plan covers up to 100 days 
in aSNF $0 copay per day for days 1-20 
$196 copay per day for days 
21-100 $0 copay per day for days 1-20 
$196 copay per day for days 
21-100 
PHYSICAL THERAPY 
Cost share may vary depending 
on the service and where service