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1 7111"y; <br />Medical <br />20% of the Medicare -allowed <br />40% of the Medicare -allowed <br />Equipment and <br />amount for all plan approved, <br />amount after $2,000 <br />Supplies 0 <br />Medicare -covered motorized <br />out -of -network deductible <br />wheelchairs and electric scooters <br />(Authorization <br />applies to <br />0% of the Medicare -allowed <br />in -network services <br />amount for all other plan <br />only.) <br />approved, Medicare -covered <br />durable medical equipment <br />Occupational and <br />■ <br />$35 copay per visit 0 <br />40% of the Medicare -allowed <br />Speech Therapy <br />amount after $2,000 <br />out -of -network deductible <br />Telehealth 0 <br />■ <br />$30 copay for Urgently Needed <br />40% of the Medicare -allowed <br />Services <br />amount after $2,000 <br />(Authorization <br />. <br />$25 copay for Primary Care <br />out -of -network deductible <br />applies to <br />Services <br />in -network services <br />. <br />$35 copay for Occupational <br />only) <br />Therapy/Physical <br />Therapy/Speech Therapy at all <br />locations <br />■ <br />$45 copay for Dermatology <br />Services <br />■ <br />$40 copay for individual sessions <br />for outpatient Mental Health <br />Specialty Services <br />■ <br />$40 copay for individual sessions <br />for outpatient Psychiatry <br />Specialty Services <br />■ <br />$40 copay for Opioid Treatment <br />Program Services <br />■ <br />$40 copay for individual sessions <br />for outpatient Substance Abuse <br />Specialty Services in an office <br />setting <br />x <br />$0 copay for Diabetes <br />Self -Management Training <br />■ <br />$0 copay for Dietician Services <br />13 <br />