Covered Services: All plans offered on the Marketplace cover 10 Essential Health Benefits:

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Introduction

The NY State of Health 2015 Plan Compare provides information about health plans offered on

the Individual Marketplace. Here's some general information to get you started.

Metal Levels: Plans offered on the NY State of Health are available at four metal levels:

Platinum, Gold, Silver and Bronze. Platinum plans have the lowest out-of-pocket cost if you use

a service, but the highest premium. Bronze plans have the highest out-of- pocket cost, but the

lowest premium.

Covered Services: All plans offered on the Marketplace cover 10 Essential Health Benefits:



Ambulatory Patient Services



Emergency Services



Inpatient Care



Maternity and New Born Care



Mental Health and Substance Use Services



Prescription Drugs



Rehabilitative Care



Laboratory Services



Preventive, Wellness and Chronic Disease Management



Pediatric Services, including vision care

Standard and Non-Standard Plans: NY State of Health offers two types of plans: standard

plans and non-standard plans. To make it easier to compare options, standard plans cover the

same services and have the same out-of-pocket costs regardless of the insurer. The primary

differences are the monthly premium charged by the insurer, the insurer’s provider network and

prescription drug formulary, and the plan’s quality rating.

Non-standard plans were designed to give you additional choices. Non-standard plans cover the

same ten Essential Health Benefits as the standard plan, but they may also cover extra services

like dental and/or vision care for adults. Non-standard plan may also have different

out-of-pocket costs.

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 The Plan Compare is organized by county. Find the section for the county in which you

reside. It will include information about all of the health plan options available to you and

your family through the Marketplace.

 At the top of each page, you will find information that identifies the name of the insurer,

the name of the plan, the plan’s identification number and the metal level. The Plan

Compare allows you to preview all of the plan options in your county, or select plans

offered by certain insurers or at certain metal levels.

 Each page in the Health Plan Compare shows the standard plan and the plan you are

reviewing so you can see how it compares. Pay particular attention to any difference in

out-of-pocket costs and any additional services covered by the plan.

 The Plan Compare does not include monthly premium because the amount you will pay

each month will depend on your income and family size when you apply for coverage.

To see if you may qualify for financial assistance to reduce your monthly cost, visit the

NY State of Health website.

 You can review the Plan Compare while you are on the website, or if it is more

convenient you can print one or more pages and review them later.

The Health Plan Compare is intended to allow you to preview the plans offered on the Individual

Marketplace. Before you select and enroll in a health plan, find out which health care providers

participate in the health plan’s network and, if you take medication, find out if they are covered

by the health plans’ formulary or list of covered drugs.

You can find the plan’s customer service numbers and provider directory links on our website at:

http://info.nystateofhealth.ny.gov/resource/health-plan-customer-service-phone-numbers-and-provider-networks

Questions or need assistance? Visit our website at

www.nystateofhealth.ny.gov

, call our

Customer Service Center at

1-855-355-5777

or meet with a NY State of Health in-person assistor

in your area.

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Livingston County

Individual Market Products

Plan

Standard

Non-Standard

Excellus

X

Fidelis

X

Health Republic

X

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Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25 HIOS Plan ID: 78124NY0900004

Metal Level: Bronze

In-Network Benefits:☒ Out-of-Network Benefits: ☐

Benefit Description Standard Bronze Benefits

Deductible • Individual Policy • Family Policy $3,000 $6,000 Maximum Out of Pocket

• Individual Policy • Family Policy

$6,350 $12,700

PCP Visit 50% coinsurance

Specialist Visit 50% coinsurance Preventive Care 0% coinsurance Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment Inpatient Services 50% coinsurance Emergency Room 50% coinsurance

Urgent Care 50% coinsurance

Durable Medical Equipment 50% coinsurance Covered Therapies (PT/OT/ST) 50% coinsurance Diagnostic & Routine Lab Services 50% coinsurance Diagnostic & Routine Imaging 50% coinsurance Outpatient Surgery Services 50% coinsurance Home Health Care Services 50% coinsurance Outpatient Behavioral Health 50% coinsurance Pediatric Basic Dental Care 50% coinsurance Pediatric Vision Care 50% coinsurance

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Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY0890010

Metal Level: Silver

Benefit Description Standard Silver Benefits

Deductible

$2,000 $4,000 Maximum Out of Pocket

$5,500 $11,000

PCP Visit $30 copayment

Specialist Visit $50 copayment Preventive Care $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment Inpatient Services $1500 copayment

Emergency Room $150 copayment

Urgent Care $70 copayment

Durable Medical Equipment 30% coinsurance Covered Therapies (PT/OT/ST) $30 copayment Diagnostic & Routine Lab Services $50 copayment Diagnostic & Routine Imaging $50 copayment Outpatient Surgery Services $100 copayment Home Health Care Services $30 copayment Outpatient Behavioral Health $30 copayment Pediatric Basic Dental Care $30 copayment Pediatric Vision Care $30 copayment

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Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY0890010-04

Metal Level: Silver Cost Share Reduction, 200-250% FPL

Benefit Description Standard Silver Benefits, 200-250% FPL

Deductible

$5,200 $10,400

Specialist Visit $50 copayment Preventive Care Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment Inpatient Services $1,500 copayment Emergency Room $150 copayment

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Deductible

$250 $500 Maximum Out of Pocket

$2,000 $4,000

Specialist Visit $35 copayment Preventive Care $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $9 copayment $20 copayment $40 copayment Inpatient Services $250 copayment Emergency Room $75 copayment

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Deductible

$1,000 $2,000

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Plan Name: Excellus Blue Cross Blue Shield Product Name: Gold Standard Gold ST INN Dep25 HIOS Plan ID: 78124NY0890004

Metal Level: Gold

Benefit Description Standard Gold Benefits

Deductible

$600 $1,200 Maximum Out of Pocket

$4,000 $8,000

Specialist Visit $40 copayment Preventive Care $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment Inpatient Services $1,000 copayment Emergency Room $150 copayment

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Product Name: Platinum Standard Platinum ST INN Dep25 HIOS Plan ID: 78124NY0880004

Metal Level: Platinum

In-Network Benefits:☒ Out-of-Network Benefits: ☐

Benefit Description Standard Platinum Benefits

Deductible

$2,000 $4,000

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Product Name: Bronze Standard Bronze ST INN Dep29 HIOS Plan ID: 78124NY0900002

$6,350 $12,700

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Product Name: Silver Standard Silver ST INN Dep29 HIOS Plan ID: 78124NY0890008

Deductible

$5,500 $11,000

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Deductible

$5,200 $10,400

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Deductible

$2,000 $4,000

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Deductible

$1,000 $2,000

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Plan Name: Excellus Blue Cross Blue Shield Product Name: Gold Standard Gold ST INN Dep29 HIOS Plan ID: 78124NY0890002

Deductible

$4,000 $8,000

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Product Name: Platinum Standard Platinum ST INN Dep29 HIOS Plan ID: 78124NY0880002

Deductible

$2,000 $4,000

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Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29 HIOS Plan ID: 78124NY0900012

Benefit Description Standard Bronze Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $3,000 $6,000 $4,500 $9,000 Maximum Out of Pocket

• Individual Policy • Family Policy $6,350 $12,700 $6,350 $12,700

PCP Visit 50% coinsurance 50% coinsurance Specialist Visit 50% coinsurance 50% coinsurance Preventive Care 0% coinsurance $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment 40% coinsurance 50% coinsurance Inpatient Services 50% coinsurance 50% coinsurance Emergency Room 50% coinsurance 50% coinsurance Urgent Care 50% coinsurance 50% coinsurance Durable Medical Equipment 50% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

50% coinsurance 50% coinsurance

Diagnostic & Routine Lab Services

Diagnostic & Routine Imaging

Outpatient Surgery Services 50% coinsurance 50% coinsurance Home Health Care Services 50% coinsurance 50% coinsurance Outpatient Behavioral Health 50% coinsurance 50% coinsurance Pediatric Basic Dental Care 50% coinsurance

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Product Name: Bronze Select Bronze NS INN Dep25 HIOS Plan ID: 78124NY0900014

PCP Visit 50% coinsurance 50% coinsurance Specialist Visit 50% coinsurance 50% coinsurance Preventive Care 0% coinsurance $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment 40% coinsurance 50% coinsurance Inpatient Services 50% coinsurance 50% coinsurance Emergency Room 50% coinsurance 50% coinsurance Urgent Care 50% coinsurance 50% coinsurance Durable Medical Equipment 50% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

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Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY0900008

Benefit Description Standard Silver Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $2,000 $4,000 $2,000 $4,000 Maximum Out of Pocket

PCP Visit $30 copayment 20% coinsurance Specialist Visit $50 copayment 20% coinsurance Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $45 copayment $90 copayment Inpatient Services $1500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care $70 copayment 20% coinsurance Durable Medical Equipment 30% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

$30 copayment 20% coinsurance

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Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY0900008-04

Benefit Description Standard Silver Benefits, 200-250% FPL

How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $1,200 $2,400 $2,000 $4,000 Maximum Out of Pocket

PCP Visit $30 copayment 20% coinsurance Specialist Visit $50 copayment 20% coinsurance

Preventive Care $0 copayment

Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $5 copayment $45 copayment $90 copayment Inpatient Services $1,500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care $70 copayment 20% coinsurance Durable Medical Equipment 25% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

(22)

How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $250 $500 $250 $500 Maximum Out of Pocket

PCP Visit $15 copayment 20% coinsurance Specialist Visit $35 copayment 20% coinsurance Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $9 copayment $20 copayment $40 copayment $5 copayment $45 copayment $90 copayment

Inpatient Services $250 copayment 20% coinsurance Emergency Room $75 copayment 20% coinsurance Urgent Care $50 copayment 20% coinsurance Durable Medical Equipment 10% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

(23)

(PT/OT/ST)

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Product Name: Silver Select Silver NS INN Dep25 HIOS Plan ID: 78124NY0900010

(PT/OT/ST)

(25)

PCP Visit $30 copayment 20% coinsurance Specialist Visit $50 copayment 20% coinsurance

Preventive Care $0 copayment

Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $5 copayment $45 copayment $90 copayment Inpatient Services $1,500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care $70 copayment 20% coinsurance Durable Medical Equipment 25% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

(26)

(PT/OT/ST)

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(PT/OT/ST)

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Product Name: Gold Select Gold NS INN Dep29 HIOS Plan ID: 78124NY0890014

Benefit Description Standard Gold Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $600 $1,200 $600 $1,200 Maximum Out of Pocket

PCP Visit $25 copayment $25 copayment Specialist Visit $40 copayment $40 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $5 copayment $35 copayment $70 copayment

Inpatient Services $1,000 copayment $750 copayment Emergency Room $150 copayment $250 copayment Urgent Care $60 copayment $40 copayment Durable Medical Equipment 20% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

$30 copayment $40 copayment

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Product Name: Gold Select Gold NS INN Dep25 HIOS Plan ID: 78124NY0890016

Benefit Description Standard Gold Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $600 $1,200 $600 $1,200 Maximum Out of Pocket

PCP Visit $25 copayment $25 copayment Specialist Visit $40 copayment $40 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $5 copayment $35 copayment $70 copayment Inpatient Services $1,000 copayment $750 copayment Emergency Room $150 copayment $250 copayment Urgent Care $60 copayment $40 copayment Durable Medical Equipment 20% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

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Product Name: Platinum Select Platinum NS INN Dep29 HIOS Plan ID: 78124NY0880008

Benefit Description Standard Platinum Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $0 $0 $0 $0 Maximum Out of Pocket

• Individual Policy • Family Policy $2,000 $4,000 $6,350 $12,700 PCP Visit $15 copayment $15 copayment Specialist Visit $35 copayment $25 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $30 copayment $60 copayment $5 copayment $25 copayment $60 copayment Inpatient Services $500 copayment $150 copayment Emergency Room $100 copayment $75 copayment Urgent Care $60 copayment $25 copayment Durable Medical Equipment 20% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

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Product Name: Platinum Select Platinum NS INN Dep25 HIOS Plan ID: 78124NY0880010

Benefit Description Standard Platinum Benefits How Does this Non-Standard Product Compare? Deductible • Individual Policy • Family Policy $0 $0 $0 $0 Maximum Out of Pocket

• Individual Policy • Family Policy $2,000 $4,000 $6,350 $12,700 PCP Visit $15 copayment $15 copayment Specialist Visit $35 copayment $25 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $30 copayment $60 copayment $5 copayment $25 copayment $50 copayment Inpatient Services $500 copayment $150 copayment Emergency Room $100 copayment $75 copayment Urgent Care $60 copayment $25 copayment Durable Medical Equipment 20% coinsurance 50% coinsurance Covered Therapies

(PT/OT/ST)

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Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY0010001

$6,350 $12,700

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Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY0020001

Deductible

$5,500 $11,000

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Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY0020001-04

Deductible

$5,200 $10,400

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Deductible

$2,000 $4,000

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Deductible

$1,000 $2,000

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Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY0030001

Deductible

$4,000 $8,000

(38)

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY0040001

Deductible

$2,000 $4,000

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Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY0110001

$6,350 $12,700

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Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY0140001

Deductible

$5,500 $11,000

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Deductible

$5,200 $10,400

(42)

Deductible

$2,000 $4,000

(43)

Deductible

$1,000 $2,000

(44)

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY0170001

Deductible

$4,000 $8,000

(45)

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY0200001

Deductible

$2,000 $4,000

(46)

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY0030001

Additional Non-Standard Benefits: Acupuncture

• Individual Policy • Family Policy $6,350 $12,700 $6,350 $12,700 PCP Visit 50% coinsurance $75 copayment Specialist Visit 50% coinsurance $75 copayment Preventive Care 0% coinsurance $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $35 copayment $70 copayment Inpatient Services 50% coinsurance 20% coinsurance Emergency Room 50% coinsurance $300 coinsurance Urgent Care 50% coinsurance $100 coinsurance Durable Medical Equipment 50% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

50% coinsurance $75 coinsurance

50% coinsurance $75 copayment

(47)

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY0130001

• Individual Policy • Family Policy $5,500 $11,000 $6,350 $12,700 PCP Visit $30 copayment $75 copayment Specialist Visit $50 copayment $75 copayment Preventive Care $0 copayment $ copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $35 copayment $70 copayment Inpatient Services $1500 copayment 20% coinsurance Emergency Room $150 copayment $300 coinsurance Urgent Care $70 copayment $100 coinsurance Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

$30 copayment $75 coinsurance

(48)

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy Naturopathy

HIOS Plan ID: 71644NY0670001 Metal Level: Bronze

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

• Individual Policy • Family Policy $5,500 $11,000 $6,500 $13,000 PCP Visit $30 copayment $0 copayment Specialist Visit $50 copayment $0 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $30 copayment $0 copayment $0 copayment Inpatient Services $1500 copayment $0 copayment Emergency Room $150 copayment $0 copayment Urgent Care $70 copayment $100 coinsurance Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

(49)

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy Naturopathy

HIOS Plan ID: 71644NY0690001 Metal Level: Bronze

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

• Individual Policy • Family Policy $5,500 $11,000 $6,500 $13,000 PCP Visit $30 copayment $0 copayment Specialist Visit $50 copayment $0 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $30 copayment $0 copayment $0 copayment Inpatient Services $1500 copayment $0 copayment Emergency Room $150 copayment $0 copayment Urgent Care $70 copayment $75 copayment Durable Medical Equipment 30% coinsurance $0 copayment Covered Therapies

(PT/OT/ST)

(50)

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY0030002

• Individual Policy • Family Policy $5,500 $11,000 $6,350 $12,700 PCP Visit $30 copayment $0 copayment Specialist Visit $50 copayment $75 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $35 copayment $70 copayment Inpatient Services $1500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $70 copayment $100 copayment Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

(51)

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY0030002-04

• Individual Policy • Family Policy $5,200 $10,400 $4,500 $9,000 PCP Visit $30 copayment $0 copayment Specialist Visit $50 copayment $75 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $35 copayment $70 copayment Inpatient Services $1,500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $70 copayment $100 copayment Durable Medical Equipment 25% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

(52)

PCP Visit $15 copayment $0 copayment Specialist Visit $35 copayment $75 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $9 copayment $20 copayment $40 copayment $10 copayment $20 copayment $40 copayment Inpatient Services $250 copayment 20% coinsurance Emergency Room $75 copayment $250 copayment Urgent Care $50 copayment $100 copayment Durable Medical Equipment 10% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

(53)

• Individual Policy • Family Policy $1,000 $2,000 $500 $1,000 PCP Visit $10 copayment $0 copayment Specialist Visit $20 copayment $75 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $6 copayment $15 copayment $30 copayment $10 copayment $15 copayment $30 copayment Inpatient Services $100 copayment 20% coinsurance Emergency Room $50 copayment $250 copayment Urgent Care $30 copayment $100 copayment Durable Medical Equipment 5% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)

(54)

Product Name: Primary Select Silver NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY0130002

• Individual Policy • Family Policy $5,500 $11,000 $6,350 $12,700 PCP Visit $30 copayment $0 copayment Specialist Visit $50 copayment $75 copayment Preventive Care $0 copayment $0 copayment Prescription Drug • Tier 1 • Tier 2 • Tier 3 $10 copayment $35 copayment $70 copayment $10 copayment $35 copayment $70 copayment Inpatient Services $1500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $70 copayment $100 copayment Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies

(PT/OT/ST)