Page 45 - APPENDICES for Janet Tuma
P. 45
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,018.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$3,450 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
$0 copay
Specialist visit
$20 copay per visit
Limits apply
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
$0-25 copay
Limits apply
Lab services
$0 copay
Limits apply
Diagnostic radiology services (like MRI)
$0-175 copay
