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10 336 <br />In -Network <br />Out -of -Network <br />Outpatient Mental Health <br />Outpatient Mental Health Services <br />Services <br />■ 40% of the Medicare -allowed amount <br />■ $40 copay <br />after $2,000 out -of -network deductible <br />Skilled Nursing <br />■ $0 copay per day for days 1-20 <br />■ 40% of the Medicare -allowed amount <br />Facility (SNF) 0 <br />. $100 copay per day for days 21- <br />after $2,000 out -of -network deductible <br />(Authorization <br />100 <br />n- <br />applies to in- <br />network <br />network <br />services only.) <br />Our plan covers up to 100 days in a SNF <br />per benefit period. <br />Physical <br />■ $35 copay per visit 0 <br />■ 40% of the Medicare -allowed amount <br />Therapy <br />after $2,000 out -of -network deductible <br />Ambulance <br />■ $200 copay for each Medicare- <br />■ $200 copay for each Medicare - <br />covered trip (one-way) 0 <br />covered trip (one-way) <br />Transportation <br />■ Not Covered <br />■ Not Covered <br />Medicare Part B <br />■ $5 copay for allergy injections <br />■ 40% of the Medicare -allowed amount <br />Drugs <br />■ 20% of the Medicare -allowed <br />after $2,000 out -of -network deductible <br />amount for chemotherapy drugs <br />and other Medicare Part B - <br />covered drugs 0 <br />10 336 <br />