Page 20 - APPENDICES for Vic Bosiger

MENTAL HEALTH SERVICES

Outpatient group therapy In-network: $15 copay Limits apply
with a psychiatrist

Outpatient individual In-network: $25 copay Limits apply
therapy with a psychiatrist

Outpatient group therapy In-network: $15 copay Limits apply
visit

Outpatient individual In-network: $25 copay Limits apply
therapy visit

OPIOID TREATMENT PROGRAM SERVICES

Opioid treatment program In-network: $0 copay Limits apply
services

OTHER SERVICES

Durable medical In-network: 20% coinsurance Limits apply
equipment (like per item
wheelchairs & oxygen)

Prosthetics (like braces, In-network: 20% coinsurance Limits apply
arti cial limbs) per item

Dialysis In-network: 20% coinsurance Limits apply

Diabetes supplies In-network: $0 copay per item Limits apply