Page 48 - APPENDICES for Stephen Spero
P. 48
Limits apply
Outpatient x-rays
$10 copay
Limits apply
Emergency care
$90 copay per visit (always covered)
Urgent care
$30 copay per visit (always covered)
HOSPITAL SERVICES
Inpatient hospital coverage
$295 per day for days 1 through 7
$0 per day for days 8 through 90
Limits apply
Outpatient hospital coverage
$0-325 copay per visit
Limits apply
SKILLED NURSING FACILITY
Skilled nursing facility
$0 per day for days 1 through 20
$140 per day for days 21 through 100
Limits apply
PREVENTIVE SERVICES
Preventive services
$0 copay
