Page 35 - APPENDICES for Diane Falten
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HOSPITAL SERVICES
Inpatient hospital In-network: $345 per day for Limits apply
coverage days 1 through 5
$0 per day for days 6 through
90
Out-of-network: Not
Applicable
Outpatient hospital In-network: $0-350 copay per Limits apply
coverage visit
Out-of-network: $400 copay
per visit
SKILLED NURSING FACILITY
Skilled nursing facility In-network: $0 per day for Limits apply
days 1 through 20
$178 per day for days 21
through 100
Out-of-network: Not
Applicable
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
AMBULANCE
Ground ambulance In-network: $295 copay
Out-of-network: $295 copay
