Page 78 - APPENDICES for Diane Falten

THERAPY SERVICES

Occupational therapy visit In-network: $40 copay
Out-of-network: 30%
coinsurance

Physical therapy & speech In-network: $40 copay
& language therapy visit Out-of-network: 30%
coinsurance

MENTAL HEALTH SERVICES

Outpatient group therapy In-network: $25 copay

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

Outpatient individual In-network: $25 copay
therapy with a psychiatrist Out-of-network: 30%
coinsurance

Outpatient group therapy In-network: $25 copay
visit Out-of-network: 30%
coinsurance

Outpatient individual In-network: $25 copay
therapy visit Out-of-network: 30%
coinsurance

OPIOID TREATMENT PROGRAM SERVICES

Opioid treatment program In-network: $0 copay Limits apply

services Out-of- 30%
network: coinsurance