Page 27 - APPENDICES for Janet Tuma
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ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,282.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$8,250 In and Out-of-network
$3,950 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
In-network: $0 copay
Out-of-network: $25 copay per visit
Specialist visit
In-network: $35 copay per visit
Out-of-network: $50 copay per visit
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
In-network: $0-75 copay
Out-of-network: 50% coinsurance
Limits apply
Lab services
In-network: $0-20 copay
Out-of-network: $30 copay
