Radiation therapy (Non-Surgical) (6) Office visit Office visit 40%(5,6) Coinsurance In Provider/Practitioner’s office 40%(5,6) Coinsurance 10%(3,4,6) 30%1,(3,4) Outpatient facility Coinsurance Coinsurance Chemotherapy (6) In Provider/Practitioner’s office Office Visit Office visit 40%(5,6) Coinsurance Outpatient facility 40%(5) Coinsurance 10%(3,4,6) 30%(1,3,4,6) Coinsurance Coinsurance Computed Axial Tomography (CAT) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Scans (6) Coinsurance Coinsurance Positron Emission Tomography (PET) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Scans (6) Coinsurance Coinsurance Magnetic Resonance Imaging (MRI) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance tests (6) 10%(3,4,6) 30%(1,3,4,6) Sleep studies (6) 40%(5,6) Coinsurance Coinsurance Coinsurance Administration of blood/blood components (6) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance RECONSTRUCTIVE SURGERY (6) Usual copayment or coinsurance based on place of treatment and type of service(1,2,3,4,5,6,7,9) EMERGENCY ROOM CARE $150(2,3) Co-pay per $150(2,3) Co-pay per $150(2,3) Co-pay per visit visit visit Including trauma services
Radiation therapy (Non-Surgical) (6) In Provider/Practitioner’s office Outpatient facility Office visit 10%(3,4,6) Coinsurance Office visit 30%1,(3,4) Coinsurance 40%(5,6) Coinsurance 40%(5,6) Coinsurance Chemotherapy (6) In Provider/Practitioner’s office Outpatient facility Office Visit 10%(3,4,6) Coinsurance Office visit 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance 40%(5) Coinsurance Computed Axial Tomography (CAT) Scans (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Positron Emission Tomography (PET) Scans (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Magnetic Resonance Imaging (MRI) tests (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Sleep studies (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Administration of blood/blood components (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance RECONSTRUCTIVE SURGERY (6) Usual copayment or coinsurance based on place of treatment and type of service(1,2,3,4,5,6,7,9) EMERGENCY ROOM CARE Including trauma services $150(2,3) Co-pay per visit $150(2,3) Co-pay per visit $150(2,3) Co-pay per visit