Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) 10% coinsurance for Facility fee (e.g., ambulatory surgery ambulatory surgery centers; 40% coinsurance center) 20% coinsurance for all If you have outpatient other facilities None surgery 10% coinsurance for ambulatory surgery center Physician/surgeon fees physicians; 40% coinsurance 20% coinsurance for all other physicians In-network deductible applies to in-network provider 20% coinsurance after 20% coinsurance after and out-of-network provider services. Emergency room care $250 copay / visit $250 copay / visit Copayment applies to facility charge for each visit (waived if admitted), whether or not the deductible has been met. If you need immediate Emergency medical 20% coinsurance 20% coinsurance In-network deductible applies to in-network provider medical attention transportation and out-of-network provider services. $60 copay / office visit, $60 copay / office visit, deductible does not apply; deductible does not apply; Copayment applies to each office visit only. All other Urgent care services are covered at the coinsurance specified, after 20% coinsurance for all 40% coinsurance for all deductible. other services other services If you have a hospital Facility fee (e.g., 20% coinsurance 40% coinsurance stay hospital room) None Physician/surgeon fees 20% coinsurance 40% coinsurance $5 copay, deductible does not apply / first 3 upfront First 3 upfront visits combined for primary care and If you need mental visits / year; behavioral health services. health, behavioral Outpatient services 40% coinsurance Copayment applies to each in-network provider office / health, or substance $30 copay / office visit after psychotherapy visit only. All other services are covered abuse services 3 upfront visits, deductible at the coinsurance specified, after deductible. does not apply; Page 4 of 7