Page 62 - APPENDICES for Janet Tuma
P. 62
Limits apply
Outpatient x-rays
$0-25 copay
Limits apply
Emergency care
$120 copay per visit (always covered)
Urgent care
$0-25 copay per visit (always covered)
HOSPITAL SERVICES
Inpatient hospital coverage
$150 per day for days 1 through 7
$0 per day for days 8 through 90
$0 per day for days 91 and beyond
Limits apply
Outpatient hospital coverage
$25-150 copay per visit
Limits apply
SKILLED NURSING FACILITY
Skilled nursing facility
$20 per day for days 1 through 20
$184 per day for days 21 through 100
Limits apply
PREVENTIVE SERVICES
Preventive services
$0 copay
