Page 18 - APPENDICES for Vic Bosiger

TESTS, LABS, & IMAGING

Diagnostic tests & In-network: $20 copay Limits apply
procedures

Lab services In-network: $0 copay Limits apply

Diagnostic radiology In-network: $0-160 copay Limits apply
services (like MRI)

Outpatient x-rays In-network: $15 copay Limits apply

Emergency care $90 copay per visit (always
covered)

Urgent care $40 copay per visit (always
covered)

HOSPITAL SERVICES

Inpatient hospital In-network: $295 per day for Limits apply
coverage days 1 through 6
$0 per day for days 7 through

90
$0 per day for days 91 and
beyond
Out-of-network: Not
Applicable

Outpatient hospital In-network: $0-295 copay per Limits apply
coverage visit