Page 85 - Cover Letter and Evaluation for Amy Prack
P. 85
Inpatient hospital coverage
In-Network: $495 per day for days 1 through 3
$0 per day for days 4 through 90
$0 per day for days 91 and beyond
Out-of-Network: $495 per day for days 1 through 3
$0 per day for days 4 through 90
Outpatient hospital coverage
In-Network: 20% per visit
Out-of-Network: $30-50 or 20% per visit
Doctor visits Primary:
In-Network: $30 per visit
Out-of-Network: $30 per visit
Specialist:
In-Network: $50 per visit
Out-of-Network: $50 per visit
Preventive care
In-Network: $0 copay
Out-of-Network: $0 copay
Emergency care/Urgent care Emergency: $90 per visit (always covered)
Urgent care: $30-50 or 20% per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures:
services/imaging In-Network: $0-50 or 20%
Out-of-Network: $30-50 or 20%
Lab services:
In-Network: $0 or 20%
Out-of-Network: $0 or 20%
Diagnostic radiology services (e.g., MRI):
In-Network: $30-50 or 20%
Out-of-Network: $30-50 or 20%
Outpatient x-rays:
In-Network: $30-50 or 20%
Out-of-Network: $30-50 or 20%
