|
Benefit: |
You
pay at
PPO Provider: |
You
pay at
Non-PPO Provider: |
|
Physical and occupational
therapy (a combined total of 50 visits per calendar year) |
- 15% of the negotiated
rate (1)
|
- 30% of the Plan
Allowance, and the difference, if any, between our allowance
and the billed amount (2)
|
|
Speech therapy
(up to 30 visits per calendar year) |
- 15% of the negotiated
rate (1)
|
- 30% of the Plan
Allowance, and the difference, if any, between our allowance
and the billed amount (2)
|
| Skilled
nursing care (50 days per year) |
- 20% and all
charges over $135 per day maximum (no deductible)
|
- 20% and all
charges over $135 per day maximum (no deductible)
|
| Pap
smear (per test) |
- 15% of the negotiated
rate (1)
|
- 30% of the Plan
Allowance, and the difference, if any, between our allowance
and the billed amount (2)
|