Page 64 - APPENDICES for Janet Tuma
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OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program services
In-network: $25-$100 copay
Limits apply
OTHER SERVICES
Durable medical equipment (like wheelchairs & oxygen)
20% coinsurance per item
Limits apply
Prosthetics (like braces, arti cial limbs)
20% coinsurance per item
Limits apply
Dialysis
In-network: 20% coinsurance
Limits apply
Diabetes supplies
$0 copay or 10-20% coinsurance per item
Limits apply
Extra bene ts & costs
HEARING
Hearing exam
$25 copay
Limits apply
