3 Type of Service Plan Pays In - Network Plan Pays Out - of - Network Home Health Care 100% after $50 copay /visit 50% after deductible Hospice Care 100% after $40 copay /visit 50% after deductible Infertility Work - up Diagnostic only - treatment not covered 100% after copay for applicable service 50% after deductible Organ Transplant – Paid like any other illness See applicable service 50% after deductible Podiatry Care Limit: Maximum of 30 days/calendar year 100% after $40 copay /visit 50% after deductible Prosthetics/Orthotics 100% after $50 copay / item 50% after deductible Radiation Therapy 100% after $200 copay /treatment 50% after deductible Short - Term Rehabilitative Therapy Speech, physical, occupational, cardiac, etc. Limit: Maximum of 50 days of treatment per calendar year for all covered therapies 100% after $ 40 copay /visit 50% after deductible Skilled Nursing Facility Limit: Maximum of 100 days of treatment per calendar year 100% after $200 copay /stay 50% after deductible MENTAL HEALTH CARE Inpatient 100% after $350 copay /admit 50% after deductible Outpatient Facility 100% after $200 copay /visit 50% after deductible Outpatient Visit 100% after $40 copay /visit 50% after deductible SUBSTANCE ABUSE TREATMENT Inpatient Hospital 100% after $350 copay /admit 50% after deductible Outpatient Facility 100% after $200 copay /visit 50% after deductible Outpatient Visit 100% after $40 copay /visit 50% after deductible