Page 76 - Appendices to Jane Miller's evaluation
P. 76
MENTAL HEALTH SERVICES
Outpatient group therapy with a psychiatrist
In-network: $15 copay
Out-of-network: $30-40 copay
Limits apply
Outpatient individual therapy with a psychiatrist
In-network: $25 copay
Out-of-network: $30-40 copay
Limits apply
Outpatient group therapy visit
In-network: $15 copay
Out-of-network: $30-40 copay
Limits apply
Outpatient individual therapy visit
In-network: $25 copay
Out-of-network: $30-40 copay
Limits apply
OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program services
In-network: $0 copay
Out-of-network: $0 copay
Limits apply
OTHER SERVICES
Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
Limits apply
