Page 78 - APPENDICES for Fred Falten

Limits apply

Diagnostic radiology services (like MRI)
In-network: $0-325 copay
Out-of-network: $20-65 copay or 30% coinsurance

Limits apply

Outpatient x-rays
In-network: $0-95 copay

Out-of-network: $20-65 copay or 30% coinsurance

Limits apply

Emergency care
$90 copay per visit (always covered)

Urgent care

$0-65 copay or 30% coinsurance per visit (always covered)

HOSPITAL SERVICES

Inpatient hospital coverage

In-network: $325 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: $500 per day for days 1 through 7

$0 per day for days 8 through 90

Limits apply

Outpatient hospital coverage
In-network: $45-325 copay per visit
Out-of-network: $65 copay or 30% coinsurance per visit

Limits apply

SKILLED NURSING FACILITY

Skilled nursing facility