Page 61 - APPENDICES for Fred Falten
P. 61
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,414.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$7,050 In and Out-of-network
$7,050 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
In-network: $0 copay
Out-of-network: $35 copay per visit
Specialist visit
In-network: $40 copay per visit
Out-of-network: $55 copay per visit
Limits apply
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
In-network: 0-15% coinsurance
Out-of-network: 0-15% coinsurance
Limits apply
Lab services
In-network: $0-5 copay or 0-20% coinsurance
Out-of-network: $0-5 copay or 0-20% coinsurance
