Covered Medical Benefits Cost if you use an In-Network Provider Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply Outpatient Hospital 25% coinsurance after medical deductible is met Pulmonary rehabilitation Office $30 copay per visit medical deductible does not apply Outpatient Hospital 25% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $30 copay per visit medical deductible does not apply Outpatient Hospital 25% coinsurance after medical deductible is met Dialysis/Hemodialysis Office $60 copay per visit medical deductible does not apply Outpatient Hospital 25% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $60 copay per visit medical deductible does not apply Outpatient Hospital 25% coinsurance after medical deductible is met Skilled Nursing Care (facility) 25% coinsurance after medical deductible is met Coverage for Inpatient rehabilitation and skilled nursing services is limited to 150 days combined per benefit period. Inpatient Hospice No charge Durable Medical Equipment 20% coinsurance medical deductible does not apply Page 4 of 10