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Your Summary of Benefits <br />Other Outpatient Services <br />20% <br />50% <br />including but not limited to: <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 90 visits <br />(excludes IV Therapy) (Network/Non-network <br />combined) <br />o Durable Medical Equipment, Orthotics <br />and Prosthetics <br />o Physical Medicine Therapy Day <br />Rehabilitation programs <br />o Hospice Care <br />20% <br />20% <br />o Ambulance Services <br />20% <br />20% <br />Accidental Dental Services $3,000 per accident <br />20% <br />50% <br />(Network and Non -network combined <br />Outpatient Therapy Services <br />(Combined Network & Non -Network limits apply) <br />o Physician Home and Office Visits <br />20% <br />50% <br />o Other Outpatient Services @ Hospital/Alternative <br />20% <br />50% <br />Care Facility <br />Limits apply to: <br />o Cardiac Rehabilitation: Unlimited <br />o Pulmonary Rehabilitation: Unlimited <br />o Physical therapy: 60 visits <br />o Occupational therapy: 60 visits <br />o Manipulation therapy: 12 visits <br />_ o_ Speech therapy:40 visits <br />Behavioral Health Services: <br />Benefits provided in <br />50°/0 <br />Mental Illness and Substance Abuse' <br />accordance with Federal <br />o Inpatient Facility Services <br />Mental Health Parity <br />o Physician Home and Office Visits <br />o Other Outpatient Services @ Hospital/Alternative <br />Care Facility <br />Human Organ and Tissue Transplants <br />o Acquisition and transplant procedures, <br />20% <br />50% <br />harvest and storage. <br />