Page 62 - APPENDICES for Fred Falten

Limits apply

Diagnostic radiology services (like MRI)
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Limits apply

Outpatient x-rays
In-network: 15% coinsurance

Out-of-network: 15% coinsurance

Limits apply

Emergency care
$90 copay per visit (always covered)

Urgent care

$40 copay per visit (always covered)

HOSPITAL SERVICES

Inpatient hospital coverage

In-network: $333 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: Not Applicable

Limits apply

Outpatient hospital coverage

In-network: $0-350 copay per visit
Out-of-network: $400 copay per visit

Limits apply

SKILLED NURSING FACILITY

Skilled nursing facility
In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100