Richmond Community School Trust HealthSync Opti POS HSA 3 Tier Opt E3 Rx Carved out -Custom Page 4 of 7 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Home Health Care Coverage is limited to 120 visits per benefit period. Limits are combined for all home health services. 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Therapy Services 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 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Manipulation Therapy office and outpatient hospital Coverage is limited to 12 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Pulmonary rehabilitation office and outpatient hospital Coverage is limited to 20 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Cardiac rehabilitation office and outpatient hospital Coverage is limited to 36 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Dialysis/Hemodialysis office and outpatient hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Chemo/Radiation Therapy office and outpatient hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Skilled Nursing Care (facility) Coverage for Skilled Nursing, Outpatient Rehabilitation and Inpatient Rehabilitation facility settings is limited to 150 days combined per benefit period. 20% coinsurance after deductible is met $500 copay per admission and 40% coinsurance after deductible is met 50% coinsurance after deductible is met Inpatient Hospice 20% coinsurance after deductible is met Same as In-Network Tier 1 Covered as In-Network Additional Services, Equipment and Devices Durable Medical Equipment 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met