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$85.00
Diabites Pump & Supplies
Insurance Responsibility
$71.76
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Insurance claim and all neccessary dependencies will be submitted to your insurer for the covered portion of this order.

Aetna - Open Access Aetna - OAP
Patient Balance
$13.24
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Insurance claim and all neccessary dependencies will be submitted to your insurer for the covered portion of this order.

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Order Recap
contracted Price $186.86
Amount Deductible $0.0
Coinsurance(0%) + $0.0
Copayment + 40.00
Total Deductible,
Coinsurance and copay $40.00
Maximum out-of-pocket
on insurance policy $40.00
Insurance Responsibility $71.76
Patient Balance $13.24
Total $85.00