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 
21-100 30% of the cost for days 1-100 You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please