Network
20% coinsurance after deductible
Non-Network
40% coinsurance after deductible
Network
20% coinsurance after deductible
Non-Network
40% coinsurance after deductible
Network
20% coinsurance after deductible
Non-Network
40% coinsurance after deductible
Coverage is allowed up to 120 days per calendar year.
Preauthorization by medical plan required.
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