Page 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In - Network (You will pay the least) Out - of - Network (You will pay the most) If you need immediate medical attention Emergency room care No charge No charge Deductible applies first Emergency medical transportation No charge No charge Deductible applies first Urgent care No charge 20% coinsurance Deductible applies first ; a telehealth cost share may be applicable If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Deductible applies first; pre - authorization / authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre - authorization / authorization required for certain services If you need mental health, behavioral health, or substance abuse services Outpatient services No charge 20% coinsurance Deductible applies first; a telehealth cost share may be applicable ; pre - authorization required for certain services Inpatient services No charge 20% coinsurance Deductible applies first; pre - authorization / authorization required for certain services If you are pregnant Office visits No charge 20% coinsurance Deductible applies first except for in - network prenatal care; cost sharing does not apply for in - network preventive service s ; maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) ; a telehealth cost share may be applicable Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance