Page 74 - Appendices to Donald Pender's Evaluation
P. 74
TESTS, LABS, & IMAGING
Diagnostic tests & $0 copay Limits apply
procedures
Lab services $0 copay Limits apply
Diagnostic radiology $20 copay Limits apply
services (like MRI)
Outpatient x-rays $0 copay Limits apply
Emergency care $85 copay per visit (always
covered)
Urgent care $5 copay per visit (always
covered)
HOSPITAL SERVICES
Inpatient hospital $0 copay Limits apply
coverage
Outpatient hospital $150 copay per visit Limits apply
coverage
SKILLED NURSING FACILITY
Skilled nursing facility $0 per day for days 1 through Limits apply
20
$50 per day for days 21
through 100
