Laserfiche WebLink
In -Network <br />Mental Health <br />Inpatient Mental Health Services <br />Services 0 <br />• $200 copay per day for days 1-7 <br />(Authorization <br />■ $0 copay per day for days 8-90 <br />applies to <br />190 -day lifetime benefit maximum in <br />in -network <br />a psychiatric hospital. <br />services only) <br />Outpatient Mental Health Services <br />■ $40 copay <br />Skilled Nursing <br />Facility (SNF) 0 <br />(Authorization <br />applies to <br />in -network <br />services only.) <br />Physical Therapy <br />■ $0 copay per day for days 1-20 <br />■ $100 copay per day for days <br />21-100 <br />Out -of -Network <br />■ Member must pay 100% of the <br />charges and submit the <br />itemized receipt(s) for <br />reimbursement of 50% of the <br />in -network allowed amount for <br />lenses, frames, contacts or <br />upgrades. Member is <br />responsible for all amounts in <br />excess of the 500/o of the <br />in -network allowed amount <br />and/or any amounts in excess of <br />the annual maximum plan <br />benefit allowance for lenses, <br />frames, contacts or upgrades. <br />■ Total reimbursement is subject to <br />the annual maximum plan benefit <br />_ allowance. <br />Inpatient Mental Health Services <br />ices <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />190 -day lifetime benefit maximum in <br />a psychiatric hospital. <br />Outpatient Mental Health Services <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />Our plan covers up to 100 days in a SNF per benefit period. <br />■ $35 copay per visit 0 <br />■ $0 copay for Lymphedema <br />Therapy <br />10 <br />• 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />