Page 42 - APPENDICES for Vic Bosiger
P. 42
TESTS, LABS, & IMAGING
Diagnostic tests & $0-85 copay Limits apply
procedures
Lab services $0 copay Limits apply
Diagnostic radiology $0-275 copay Limits apply
services (like MRI)
Outpatient x-rays $0-85 copay Limits apply
Emergency care $90 copay per visit (always
covered)
Urgent care $25 copay per visit (always
covered)
HOSPITAL SERVICES
Inpatient hospital $275 per day for days 1 Limits apply
coverage through 6
$0 per day for days 7 through
90
Outpatient hospital $285 copay per visit Limits apply
coverage
