Page 29 - APPENDICES for Janet Tuma

Out-of-network: 50% per stay
Limits apply

PREVENTIVE SERVICES

Preventive services
In-network: $0 copay

Out-of-network: 0-50% coinsurance

AMBULANCE

Ground ambulance

In-network: $300 copay
Out-of-network: $300 copay

THERAPY SERVICES

Occupational therapy visit
In-network: $40 copay
Out-of-network: 50% coinsurance

Limits apply

Physical therapy & speech & language therapy visit
In-network: $40 copay
Out-of-network: $50 copay

Limits apply

MENTAL HEALTH SERVICES

Outpatient group therapy with a psychiatrist
In-network: $40 copay
Out-of-network: 50% coinsurance

Limits apply