ELIGIBLE |
Pay

$85.00

Diabetes Pump & Supplies

Insurance Responsibility $71.76

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Insurance claims and all necessary dependencies will be submitted to your insurer for the coverred portion of this order

Aetna-Open Access
OAP

Patient Balance $13.24

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This is an estimate for the portion of your order (not covered by insurance) due today . once insurance finalizes their review refunds and/or balances will reconcile automatically.

Visa Debit Card

************3456

Mastercard Office

************1038

Order Recap

Contracted Price
$186.76
Amount toward deductible
$0.00
Coinsurance( 0% )
+ $0.00
Copayment
+ $40.00
Total Deductible, Coinsurance, and Copay
$40.00
Maximum out-of-pocket on Insurance Policy (not reached)
$6500.00
Insurance Responsibility
$71.76
Patient Balance
$71.76
Total
$85.00