Page 19 - APPENDICES for Vic Bosiger

SKILLED NURSING FACILITY

Skilled nursing facility In-network: $0 per day for Limits apply
days 1 through 20
$188 per day for days 21

through 52
$0 per day for days 53
through 100
Out-of-network: Not
Applicable

PREVENTIVE SERVICES

Health care to prevent illness or detect illness at an early stage, when treatment is likely
to work best (like Pap tests, u shots, and screening mammograms).

Learn more about your costs for preventive services

Preventive services In-network: $0 copay

AMBULANCE

Ground ambulance In-network: $265 copay

THERAPY SERVICES

Occupational therapy visit In-network: $20 copay Limits apply

Physical therapy & speech In-network: $20 copay Limits apply
& language therapy visit