Page 87 - Appendices to Jane Miller's evaluation
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$200.00
ESTIMATED YEARLY COSTS
Estimated total yearly costs for care
$3,498.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services
$11,300 In and Out-of-network
$7,550 In-network
Bene ts & costs
DOCTOR SERVICES View Provider Network Directory
Primary doctor visit
In-network: $10 copay per visit
Out-of-network: 40% coinsurance per visit
Specialist visit
In-network: $45 copay per visit
Out-of-network: 40% coinsurance per visit
TESTS, LABS, & IMAGING
Diagnostic tests & procedures
In-network: $0-20 copay
Out-of-network: 40% coinsurance
Limits apply
