Page 45 - Appendices for Eric Hartman
P. 45
TESTS, LABS, & IMAGING
Diagnostic tests & $5 copay Limits apply
procedures
Lab services $0 copay Limits apply
Diagnostic radiology $0-75 copay Limits apply
services (like MRI)
Outpatient x-rays $0 copay Limits apply
Emergency care $90 copay per visit (always
covered)
Urgent care $0 copay
HOSPITAL SERVICES
Inpatient hospital $0 copay Limits apply
coverage
Outpatient hospital $225 copay per visit Limits apply
coverage
