Page 79 - APPENDICES for Fred Falten

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 100

Out-of-network: 30% per stay

Limits apply

PREVENTIVE SERVICES

Preventive services
In-network: $0 copay
Out-of-network: $0-65 copay or 30% coinsurance

AMBULANCE

Ground ambulance
In-network: $290 copay
Out-of-network: $290 copay

THERAPY SERVICES

Occupational therapy visit

In-network: $40 copay
Out-of-network: $65 copay or 30% coinsurance

Limits apply

Physical therapy & speech & language therapy visit
In-network: $40 copay
Out-of-network: $65 copay or 30% coinsurance

Limits apply

MENTAL HEALTH SERVICES

Outpatient group therapy with a psychiatrist

In-network: $40 copay
Out-of-network: $65 copay