Page 51 - APPENDICES for Neill McLauchlin
P. 51
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,114.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$11,000 In and Out-of-network
$5,750 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
In-network: $0 copay
Out-of-network: $40 copay per visit
Specialist visit
In-network: $25 copay per visit
Out-of-network: $55 copay per visit
Limits apply
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
In-network: $0-95 copay
Out-of-network: 30% coinsurance
Limits apply
Lab services
In-network: $0 copay
Out-of-network: 0-30% coinsurance
