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., hospital room) $1,000 / admission 20% coinsurance authorization / authorization required If you have a hospital stay for certain services Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization / authorization required for certain services Deductible applies first; a telehealth Outpatient services $60 / visit 20% coinsurance 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 20% coinsurance authorization / authorization required for certain services Office visits No charge 20% coinsurance Deductible applies first except for in- Childbirth/delivery professional services No charge 20% coinsurance network prenatal care; cost sharing does not apply for in-network If you are pregnant preventive services; maternity care Childbirth/delivery facility services $1,000 / admission 20% coinsurance may include tests and services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Page 4 of 8