Page 80 - APPENDICES for Fred Falten
P. 80
Limits apply
Outpatient individual therapy with a psychiatrist
In-network: $40 copay
Out-of-network: $65 copay
Limits apply
Outpatient group therapy visit
In-network: $40 copay
Out-of-network: $65 copay
Limits apply
Outpatient individual therapy visit
In-network: $40 copay
Out-of-network: $65 copay
Limits apply
OPIOID TREATMENT PROGRAM SERVICES
Opioid treatment program services
In-network: $40-$100 copay
Out-of-network: $65 copay
30% coinsurance
Limits apply
OTHER SERVICES
Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Limits apply
Prosthetics (like braces, arti cial limbs)
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Limits apply
