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16 <br /> Category Traditional Plan PPO PP. <br /> Preferred Non-Preferred <br /> Ambulance Services see section B: Special Services <br /> Accidental Injua <br /> Outpatient 100% PRC 90% PRC 80% PRC <br /> When treated within <br /> 3 days of accident <br /> When treated within 100% PRC 90%PRC 90%PRC <br /> 24 hours of accident <br /> Inpatient 80%covered 90% covered 80% PRC <br /> Short Term <br /> Rehabilitation 80%covered 90% covered 80%PRC <br /> Up to 70 days in a semi- <br /> private facility (After <br /> 70 days, additional days <br /> allowed if hospitalized) <br /> Physical Therapy 80%covered 90% covered 80%PRC <br /> Medically necessary <br /> and given by eligible <br /> provider <br /> Mental Health <br /> Outpatient 50%covered 70%covered 50% PRC <br /> up to $2,000 <br /> Inpatient 80%covered 90%covered 80% PRC <br /> Mental Health n/a $6,000 p/member $6,000 p/member <br /> Calendar year <br /> Maximum <br /> Mental Health <br /> Lifetime Maximum $10,000 p/member $25,000 p/member $25,000 p/member <br />