Diagnostic tests and procedures $0 to  $90 copay 30% of the cost 
Outpatient X-rays $10 to  $90 copay 30% of the cost 
Radiation therapy $40 copay or  20% of the cost 20% of the cost 
HEARING SERVICES 
Medicare-covered hearing $40 copay 30% of the cost You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please