Covered Medical Benefits Cost if you use an In-Network Provider Outpatient Hospital $125 copay per visit medical deductible does not apply 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. $25 copay per visit medical deductible does not apply Emergency Room Facility Services In-Network and Out-of-Network Providers: Your copay will be waived if admitted. $250 copay per visit and 30% coinsurance after medical deductible is met 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 medical deductible does not apply Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge Outpatient Surgery Facility Fees Hospital 30% coinsurance after medical deductible is met Ambulatory Surgical Center 30% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees 30% coinsurance after medical deductible is met Physician and other services including surgeon fees No charge Home Health Care $25 copay per visit medical deductible does not Coverage is limited to 100 visits per benefit period. apply Page 3 of 10