•Your plan covers up to 190 days in alifetime for inpatient mental 
health care in apsychiatric hospital. 
Outpatient (group and individual therapy visits):  $25 to  $100 copay 
Cost share may vary depending on where service is provided. 
Skilled nursing facility (SNF) •$0 copay per day for days 1-20 
•$150 copay per day for days 21-100 
•Your plan covers up to 100 days in aSNF 
Physical Therapy  
Cost share may vary depending 
on the service and where service 
is provided. •$15 to  $30 copay