Page 66 - APPENDICES for Vic Bosiger
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AMBULANCE
Ground ambulance In-network: $290 copay
Out-of-network: $290 copay
THERAPY SERVICES
Occupational therapy visit In-network: $10-40 copay Limits apply
Out-of-network: 40%
coinsurance
Physical therapy & speech In-network: $10-40 copay Limits apply
& language therapy visit Out-of-network: 40%
coinsurance
MENTAL HEALTH SERVICES
Outpatient group therapy In-network: $35 copay Limits apply
with a psychiatrist Out-of-network: 40%
coinsurance
Outpatient individual In-network: $35 copay Limits apply
therapy with a psychiatrist Out-of-network: 40%
coinsurance
Outpatient group therapy In-network: $35 copay Limits apply
visit Out-of-network: 40%
coinsurance
Outpatient individual In-network: $35 copay Limits apply
therapy visit Out-of-network: 40%
coinsurance
