Page 30 - APPENDICES for Janet Tuma

Outpatient individual therapy with a psychiatrist

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

Limits apply

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

Limits apply

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

Limits apply

OPIOID TREATMENT PROGRAM SERVICES

Opioid treatment program services
In-network: $40 copay

Out-of-network: 50% coinsurance

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

Prosthetics (like braces, arti cial limbs)

In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item

Limits apply

Dialysis