Page 44 - APPENDICES for Vic Bosiger
P. 44
MENTAL HEALTH SERVICES
Outpatient group therapy $30 copay Limits apply
with a psychiatrist
Outpatient individual $30 copay Limits apply
therapy with a psychiatrist
Outpatient group therapy $30 copay Limits apply
visit
Outpatient individual $30 copay Limits apply
therapy visit
OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program In-network: $0 copay
services
OTHER SERVICES
Durable medical 20% coinsurance per item Limits apply
equipment (like
wheelchairs & oxygen)
Prosthetics (like braces, 20% coinsurance per item Limits apply
arti cial limbs)
Dialysis In-network: 20% coinsurance
Diabetes supplies $0 copay Limits apply
