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Your Summary of Benefits <br />Inpatient Facility Services (Network/Non-Network <br />20% <br />40% <br />combined) Unlimited days except for: <br />a 60 days Network/Non-Network combined <br />for physical medicine/rehab (limit includes <br />Day Rehabilitation Therapy Services on an <br />outpatient basis) <br />0 90 da s for skilled nursing facility _ <br />Outpatient Surgery HospitallAlternative Care Facility <br />20% <br />40% <br />0 Surgery and administration of general anesthesia <br />Other Outpatient Services (including but not limited to): <br />20% <br />40% <br />o Non Surgical Outpatient Services <br />For example: MRIs, C-Scans, <br />Chemotherapy, Ultrasounds and <br />other diagnostic outpatient services. <br />o Home Care Services <br />(Network/Non-Network combined) <br />90 visits (excludes IV Therapy) <br />o Durable Medical Equipment and Orthotics <br />o Prosthetic Devices <br />a Prosthetic Limbs <br />o Physical Medicine Therapy Day <br />Rehabilitation programs <br />o Hospice Care <br />NCS <br />NCS <br />o Ambulance Services <br />20% <br />20% <br />Outpatient Therapy Services <br />(Combined Network & Non -Network limits apply) <br />o Physician Home and Office Visits (PCPISCP) <br />$301$60 <br />40% <br />o Other Outpatient Services @ Hospital/Alternative <br />20% <br />40% <br />Care Facility <br />Limits apply to: <br />a Physical therapy: 60 visits <br />a Occupational therapy: 60 visits <br />o Manipulation therapy: 12 visits <br />o Speech therapy: 40 visits <br />o Cardiac Rehabilitation: Unlimited <br />o Pulmonary Rehabilitation: Unlimited <br />Accidental Dental: $3,000 limit per occurrence <br />CopaymentslCoinsurance <br />40% <br />(Network and Non -network combined) <br />based on setting where <br />covered services are <br />received <br />