Page 88 - Appendices to Jane Miller's evaluation

Lab services

In-network: $0-10 copay
Out-of-network: 40% coinsurance

Limits apply

Diagnostic radiology services (like MRI)
In-network: $0-265 copay
Out-of-network: 40% coinsurance

Limits apply

Outpatient x-rays
In-network: $25 copay
Out-of-network: 40% coinsurance

Limits apply

Emergency care
$90 copay per visit (always covered)

Urgent care
$10-50 copay per visit (always covered)

HOSPITAL SERVICES

Inpatient hospital coverage
In-network: $260 per day for days 1 through 5
$0 per day for days 6 through 90

Out-of-network: 40% per stay

Limits apply

Outpatient hospital coverage
In-network: $0-350 copay per visit
Out-of-network: 40% coinsurance per visit

Limits apply

SKILLED NURSING FACILITY