Page 67 - APPENDICES for Stephen Spero

$0 copay

AMBULANCE

Ground ambulance
20% coinsurance

THERAPY SERVICES

Occupational therapy visit
20% coinsurance

Limits apply

Physical therapy & speech & language therapy visit

20% coinsurance

Limits apply

MENTAL HEALTH SERVICES

Outpatient group therapy with a psychiatrist
20% coinsurance

Limits apply

Outpatient individual therapy with a psychiatrist

20% coinsurance
Limits apply

Outpatient group therapy visit
20% coinsurance

Limits apply

Outpatient individual therapy visit
20% coinsurance

Limits apply