Page 36 - APPENDICES for Neill McLauchlin

Limits apply

Outpatient x-rays
$0-20 copay

Limits apply

Emergency care
$90 copay per visit (always covered)

Urgent care
$20 copay per visit (always covered)

HOSPITAL SERVICES

Inpatient hospital coverage

$295 per day for days 1 through 6
$0 per day for days 7 through 90

Limits apply

Outpatient hospital coverage
$0-275 copay per visit

Limits apply

SKILLED NURSING FACILITY

Skilled nursing facility

$0 per day for days 1 through 20
$184 per day for days 21 through 100

Limits apply

PREVENTIVE SERVICES

Preventive services
$0 copay