Page 53 - APPENDICES for Neill McLauchlin

Out-of-network: 30% per stay
Limits apply

PREVENTIVE SERVICES

Preventive services
In-network: $0 copay

Out-of-network: $0 copay

AMBULANCE

Ground ambulance

In-network: $220 copay
Out-of-network: $220 copay

THERAPY SERVICES

Occupational therapy visit
In-network: $25 copay
Out-of-network: $55 copay

Limits apply

Physical therapy & speech & language therapy visit
In-network: $25 copay
Out-of-network: $55 copay

Limits apply

MENTAL HEALTH SERVICES

Outpatient group therapy with a psychiatrist
In-network: $0 copay
Out-of-network: $55 copay

Limits apply