Covered Medical Benefits Cost if you use an In-Network Provider Emergency Room Facility Services In-Network and Non-Network Providers: Your copay will be waived if admitted. $125 copay per visit Emergency Room Doctor and Other Services In-Network and Non-Network Providers: No charge Ambulance In-Network and Non-Network Providers: Authorized Non-Network non-emergency ambulance services are limited $100 copay per trip to an Anthem maximum payment of $50,000 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 $250 copay per visit Ambulatory Surgical Center $250 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 $500 copay per admission Physician and other services including surgeon fees No charge Home Health Care $20 copay per visit Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $20 copay per visit Page 3 of 9