Page 70 - Appendices for Eric Hartman

AMBULANCE

Ground ambulance In-network: $250 copay
Out-of-network: 30%
coinsurance

THERAPY SERVICES

Occupational therapy visit In-network: $0 copay Limits apply
Out-of-network: 30%
coinsurance

Physical therapy & speech In-network: $0 copay Limits apply

& language therapy visit Out-of-network: 30%
coinsurance

MENTAL HEALTH SERVICES

Outpatient group therapy In-network: $40 copay Limits apply
with a psychiatrist Out-of-network: 30%
coinsurance

Outpatient individual In-network: $40 copay Limits apply

therapy with a psychiatrist Out-of-network: 30%
coinsurance

Outpatient group therapy In-network: $0 copay Limits apply
visit Out-of-network: 30%

coinsurance

Outpatient individual In-network: $0 copay Limits apply
therapy visit Out-of-network: 30%
coinsurance