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 
N/A $0 copay 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