What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) $1,000 / admission Not covered authorization required for certain If you have outpatient services surgery Deductible applies first; pre- Physician/surgeon fees No charge Not covered authorization required for certain services Deductible applies first; copayment Emergency room care $750 / visit $750 / visit waived if admitted or for observation stay If you need immediate Emergency medical transportation No charge No charge Deductible applies first medical attention Deductible applies first; out-of- Urgent care $75 / visit $75 / visit network coverage limited to out of service area; a telehealth cost share may be applicable Deductible applies first; pre- Facility fee (e.g., hospital room) $1,000 / admission Not covered authorization / authorization required If you have a hospital stay for certain services Deductible applies first; pre- Physician/surgeon fees No charge Not covered authorization / authorization required for certain services Deductible applies first; a telehealth Outpatient services $50 / visit Not covered cost share may be applicable; pre- If you need mental health, authorization required for certain behavioral health, or services substance abuse services Deductible applies first; pre- Inpatient services $1,000 / admission Not covered authorization / authorization required for certain services Office visits No charge Not covered Deductible applies first except for Childbirth/delivery professional services No charge Not covered prenatal care; cost sharing does not apply for preventive services; If you are pregnant maternity care may include tests and Childbirth/delivery facility services $1,000 / admission Not covered services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Page 3 of 7