Page 67 - APPENDICES for Vic Bosiger
P. 67
OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program In-network: $35-$85 copay Limits apply
services Out-of- 40%
network: coinsurance
OTHER SERVICES
Durable medical In-network: 20% coinsurance Limits apply
equipment (like per item
wheelchairs & oxygen) Out-of-network: 40%
coinsurance per item
Prosthetics (like braces, In-network: 20% coinsurance Limits apply
arti cial limbs) per item
Out-of-network: 40%
coinsurance per item
Dialysis In-network: 20% coinsurance Limits apply
Out-of- 20%
network: coinsurance
Diabetes supplies In-network: $0 copay or 10- Limits apply
20% coinsurance per item
Out-of-network: 40%
coinsurance per item
