Page 71 - Appendices for Eric Hartman
P. 71
OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program In-network: 20% coinsurance Limits apply
services Out-of- 30%
network: coinsurance
OTHER SERVICES
Durable medical In-network: 0-20% Limits apply
equipment (like coinsurance per item
wheelchairs & oxygen) Out-of-network: 30%
coinsurance per item
Prosthetics (like braces, In-network: 20% coinsurance Limits apply
arti cial limbs) per item
Out-of-network: 30%
coinsurance per item
Dialysis In-network: 20% coinsurance Limits apply
Out-of- 30%
network: coinsurance
Diabetes supplies In-network: $0 copay Limits apply
Out-of-network: 30%
coinsurance per item
