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Precert required; max $500 reduction

30% after deductible

Precert required; max $500 reduction

30% after deductible

Precert required; max $500 reduction

Rehab, Home & Skilled Care Rehab / Habilitative Services $20 copay/visit

20 visits combined OT/PT/Speech; 20 cardiac rehab; 15 chiro per year

$60 copay/visit

Same visit limits apply

$60 copay/visit

Same visit limits apply

Home Health Care 20% after deductible 30% after deductible 30% after deductible Skilled Nursing 20% after deductible

Up to 90 days/year

30% after deductible

Up to 60 days/year

30% after deductible

Up to 60 days/year

Durable Medical Equipment 20% after deductible 30% after deductible 30% after deductible Hospice Services 20% after deductible 30% after deductible 30% after deductible Prescription Drugs (In-Network) Generic $15 $15 $15 Brand Name $45 $65 $65 Non-Preferred Brand $85 $100 $100 Specialty Through MyRX

PAP application required

Not Covered Not Covered 31–90 Day Supply Generic $45  |  Brand $90  |  Non-Preferred Brand $150  —  Retail & Mail Order Out-of-Network Benefits Deductible (Ind / Family) $2,000 / $4,000 $6,000 / $12,000 $12,000 / $24,000 Max Out-of-Pocket (Ind / Family) $10,000 / $20,000 $18,950 / $37,900 $18,900 / $37,900 Coinsurance 60% 40% 40% Reimbursement Basis Plans Allowable Fee Ready to Enroll? Get a Quote Get a Quote Get a Quote