Page 38 - APPENDICES for Neill McLauchlin
P. 38
Opioid treatment program services
In-network: $20 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
0-20% coinsurance per item
Limits apply
Extra bene ts & costs
HEARING
Hearing exam
$0-20 copay
Fitting/evaluation
$0 copay
Limits apply
Hearing aids - Inner ear
