Page 4 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Ambulatory Surgical Center $500 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital No charge after medical deductible is met 50% coinsurance after medical deductible is met 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. Member is responsible for an additional $500 copay if prior authorization is not obtained from Anthem for non-emergency Inpatient admissions to Out-of-Network Providers. Anthem’s maximum payment is up to $1,000 per day for non-emergency Inpatient admissions to Out-of- Network Providers. Facility Fees $750 copay per admission after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees No charge after medical deductible is met 50% coinsurance after medical deductible is met Home Health Care Coverage is limited to 100 visits per benefit period. $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Therapy Services Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Pulmonary rehabilitation Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Cardiac rehabilitation