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 $750 / visit $750 / visit In - network deductible applies first for in - network and out - of - network services; copayment waived if admitted or for observation stay Emergency medical transportation No charge No charge In - network deductible applies first for in - network and out - of - network services Urgent care $60 / visit 20% coinsurance Deductible applies first ; a telehealth cost share may be applicable If you have a hospital stay Facility fee (e.g., hospital room) $1,000 / admission 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 $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable ; pre - authorization required for certain services Inpatient services $1,000 / admission 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 services ; 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 $1,000 / admission 20% coinsurance