Page 49 - Takoma Park Benefits Guide 2022
P. 49

ĞŶƚĂů ^ƵŵŵĂƌLJ ; ŽŶƟŶƵĞĚͿ



                                  ĞŶĞĮƚƐ                                      BlueDHMO Option 2

                                                      Annual Maximum
              Referral Needed                                                         EŽ

               ůĂƐƐ /͕ //͕ /// Θ /s                                           Refer to Fee Schedule


                                                       /ŶƚĞƌŶĞƚ ^ŝƚĞƐ

               ŽĐƚŽƌ WƌŽǀŝĚĞƌ ^ŝƚĞ                                            ǁǁǁ͘ĐĂƌĞĮƌƐƚ͘ĐŽŵ

                                                       DŽŶƚŚůLJ ZĂƚĞƐ

                /ŶĚŝǀŝĚƵĂů                                                            Ψ14.87
                WĂƌĞŶƚͬ ŚŝůĚ                                                          Ψ35.69
                 ŵƉůŽLJĞĞͬ^ƉŽƵƐĞ                                                       $29.74
                &ĂŵŝůLJ                                                                $57.99

             ĨĨĞĐƚŝǀĞ  ĂƚĞ͗ 05/01/2022
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