3 Type of Service/Benefit Plan Pays In-Network Plan Pays Out-of-Network Diagnostic Lab and X-ray (Physician’s Office) 100% after applicable office visit copay 70% after deductible Durable Medical Equipment Rental coverage limited to purchase price 90% after deductible 70% after deductible Habilitation Services ABA therapy only 100% after $25 copay/visit 70% after deductible Home Health 90% after deductible 70% after deductible Hospice Care 90% after deductible 70% after deductible Infertility Work-up Diagnostic only-treatment not covered 90% after deductible 70% after deductible Organ Transplant – Paid like any other illness See applicable service 70% after deductible Podiatry Care Limit: Maximum of 30 days/calendar year 100% after $25 copay/visit 70% after deductible Prosthetics/Orthotics 90% after deductible 70% after deductible Radiation Therapy 90% after deductible 70% after deductible Short - Term Rehabilitative Therapy Speech, physical, occupational, cardiac, etc. Plan A+ also includes orthoptic therapy Limit: Maximum of 50 days of treatment per calendar year for all covered therapies 100% after $25 copay/visit 70% after deductible Skilled Nursing Facility Limit: Maximum of 100 days of treatment per calendar year 90% after deductible 70% after deductible Telehealth 100% after applicable office visit copay Not Covered MENTAL HEALTH CARE Inpatient 100% after $75 copay/admit 70% after deductible Outpatient Facility 100% after $50 copay/visit 70% after deductible Outpatient Visit 100% after $20 copay/visit 70% after deductible