Covered Medical Benefits Cost if you use an In-Network Provider Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply $25 copay per visit medical deductible does not depending on the care provided. apply Emergency Room Facility Services In-Network and Out-of-Network Providers: Your copay will be waived if admitted. $150 copay per visit and then 20% coinsurance after medical deductible is met Emergency Room Doctor and Other Services In-Network and Out-of-Network Providers: 20% coinsurance after medical deductible is met Ambulance In-Network and Out-of-Network Providers: 20% coinsurance after medical deductible is met Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after medical deductible is met Doctor Services 20% coinsurance after medical deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after medical deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees 20% coinsurance after medical deductible is met Physician and other services including surgeon fees 20% coinsurance after medical deductible is met Home Health Care 20% coinsurance after medical deductible is met Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office 20% coinsurance after medical deductible is met Page 3 of 9