Covered Medical and Hospital Benefits (cont.)  
OUTPATIENT CARE AND SERVICES 
Diagnostic services, labs and 
imaging 
Cost share may vary depending 
on the service and where service 
is provided •Diagnostic mammography:  $0 to  $15 copay 
•Diagnostic colonoscopy  $0 copay 
•Diagnostic radiology:  $180 to  $300 copay 
•Lab services:  $0 to  $20 copay 
•Diagnostic tests and procedures:  $0 to  $100 copay 
•Outpatient X-rays:  $0 to  $75 copay 
•Radiation therapy:  $15 copay or  20% of the cost