Page 37 - APPENDICES for Diane Falten

OTHER SERVICES

Durable medical In-network: 20% coinsurance Limits apply
equipment (like 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- 20%
network: coinsurance

Diabetes supplies In-network: $0 copay
Out-of-network: 20%
coinsurance per item