Page 59 - APPENDICES for Diane Falten

OPIOID TREATMENT PROGRAM SERVICES

Opioid treatment program In-network: $40-$100 copay Limits apply
services Out-of- 30%
network: coinsurance

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 or 10- Limits apply

20% coinsurance per item
Out-of-network: 20-30%
coinsurance per item