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Summary of Benefits and Coverage: What this Plan Covers ...
Not Covered. Requires pre-approval. OMNIA Tier 1 in-network separation period is limited to 90 days. $2,500.00 OMNIA Tier 1 Habilitation services $500.00 Copayment copayment maximum per admission. per day for Inpatient Hospital. 50% Coinsurance for Inpatient Hospital. Not Covered. Skilled nursing care $500.00 Copayment per day for Inpatient ...
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