Page 3 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. 10% coinsurance after deductible is met 30% coinsurance after deductible is met Emergency Room Facility Services 10% coinsurance after deductible is met Covered as In-Network Emergency Room Doctor and Other Services 10% coinsurance after deductible is met Covered as In-Network Ambulance 10% coinsurance after deductible is met Covered as In-Network Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 10% coinsurance after deductible is met 30% coinsurance after deductible is met Doctor Services 10% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Surgery Facility Fees Hospital 10% coinsurance after deductible is met 30% coinsurance after deductible is met Ambulatory Surgical Center 10% coinsurance after deductible is met 30% coinsurance after deductible is met Physician and other services including surgeon fees Hospital 10% coinsurance after deductible is met 30% coinsurance after deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Anthem's maximum payment is up to $1,000 per day for non-emergency Inpatient admissions to Out-of-Network Providers. Facility Fees 10% coinsurance after deductible is met 30% coinsurance after deductible is met Physician and other services including surgeon fees 10% coinsurance after deductible is met 30% coinsurance after deductible is met Home Health Care Coverage is limited to 100 visits per benefit period. 10% coinsurance after deductible is met 30% coinsurance after deductible is met Therapy Services Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office 10% coinsurance after deductible is met 30% coinsurance after deductible is met