What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory surgery 20% coinsurance Not Covered None If you have center) outpatient surgery Physician/surgeon 20% coinsurance Not Covered None fees Emergency room 20% coinsurance 20% coinsurance None care If you need Emergency medical $150 / trip, deductible does not $150 / trip, deductible does not None immediate medical transportation apply. apply. attention Non-Plan providers covered when temporarily $25 / visit, deductible does not Urgent care Not Covered outside the service area: $25 / visit, deductible apply. does not apply. Facility fee (e.g., 20% coinsurance Not Covered None hospital room) If you have a hospital stay Physician/surgeon 20% coinsurance Not Covered None fee Mental / Behavioral Health: $25 / individual visit, deductible does not apply. 20% coinsurance for other outpatient services, deductible does not apply; Mental / Behavioral Health: $12 / group visit, If you need mental Outpatient services Substance Abuse: $25 / Not Covered deductible does not apply; Substance Abuse: health, behavioral individual visit, deductible does $5 / group visit, deductible does not apply. health, or substance not apply. 20% coinsurance up abuse services to $5 / day for other outpatient services, deductible does not apply. Inpatient services 20% coinsurance Not Covered None 3 of 8