Covered Medical Benefits Cost if you use an In-Network Provider Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply In-Network and Out-of-Network Providers: depending on the care provided. $40 copay per visit Emergency Room Facility Services In-Network and Out-of-Network Providers: Your copay will be waived if admitted. $200 copay per visit Emergency Room Doctor and Other Services In-Network and Out-of-Network Providers: No charge Ambulance In-Network and Out-of-Network Providers: $150 copay per trip Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge Outpatient Surgery Facility Fees Hospital $375 copay per visit Ambulatory Surgical Center $375 copay per visit Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees $750 copay per admission Physician and other services including surgeon fees No charge Home Health Care $40 copay per visit Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Page 3 of 9