Page 65 - APPENDICES for Vic Bosiger
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HOSPITAL SERVICES
Inpatient hospital In-network: $355 per day for Limits apply
coverage days 1 through 4
$0 per day for days 5 through
90
$0 per day for days 91 and
beyond
Out-of-network: 40% per stay
Outpatient hospital In-network: $35-355 copay Limits apply
coverage per visit
Out-of-network: 40%
coinsurance per visit
SKILLED NURSING FACILITY
Skilled nursing facility In-network: $0 per day for Limits apply
days 1 through 20
$188 per day for days 21
through 52
$0 per day for days 53
through 100
Out-of-network: 40% per stay
PREVENTIVE SERVICES
Health care to prevent illness or detect illness at an early stage, when treatment is likely
to work best (like Pap tests, u shots, and screening mammograms).
Learn more about your costs for preventive services
Preventive services In-network: $0 copay
Out-of-network: $0 copay or
40% coinsurance
