Contact lenses: $0 copay (limits apply).Routine eye exam: $0 copay (referral required).Prosthodontics, other oral/maxillofacial surgery, other services: Not covered.Extractions: $0 copay (authorization and referral required).Periodontics: $0 copay (limits apply, authorization and referral required).Diagnostic services: $0 copay (limits apply, authorization and referral required).Dental x-ray(s): $0 copay (limits apply, referral required).Cleaning: $0 copay (limits apply, referral required).Oral exam: $0 copay (limits apply, referral required).Fitting/evaluation: $0 copay (referral required).Hearing exam: $10 copay (referral required).Diabetes supplies: $0 copay (authorization required).Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required). Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required).Outpatient individual therapy visit: $0 copay.Outpatient group therapy visit: $0 copay.Outpatient individual therapy visit with a psychiatrist: $0 copay.Outpatient group therapy visit with a psychiatrist: $0 copay.$0 per day for days 91 and beyond (referral required) Inpatient hospital - psychiatric: $170 per day for days 1 through 5.Physical therapy and speech and language therapy visit: $0-10 copay (referral required).Occupational therapy visit: $5-10 copay (referral required).$100 per day for days 21 through 100 (authorization and referral required) $0 per day for days 91 and beyond (authorization and referral required) Emergency: $110 copay per visit (always covered).Outpatient x-rays: $0 copay (referral required).Diagnostic radiology services (e.g., MRI): $0-195 copay (referral required).Lab services: $0 copay (referral required).Diagnostic tests and procedures: $0 copay (referral required).
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