provided to treat a 
non-emergency, unforeseen 
medical illness, injury or condition 
that requires immediate medical 
attention. $35 copay at an urgent care 
center $35 copay at an urgent care 
center 
OUTPATIENT CARE AND DIAGNOSTIC SERVICES, LABS AND IMAGING 
Cost share may vary depending on the service and where service is provided 
Diagnostic mammography $0 to  $30 copay $0 to  $30 copay 
Diagnostic colonoscopy $0 copay $0 copay 
Diagnostic radiology $180 to  $300 copay $180 to  $300 copay