Page 77 - APPENDICES for Diane Falten

HOSPITAL SERVICES

Inpatient hospital In-network: $395 per day for Limits apply
coverage days 1 through 5
$0 per day for days 6 through

90
Out-of-network: 30% per stay

Outpatient hospital In-network: $0-350 copay per Limits apply
coverage visit
Out-of-network: 30%

coinsurance 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: 30% 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: 30%
coinsurance

AMBULANCE

Ground ambulance In-network: $295 copay
Out-of-network: $295 copay