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 have a hospital stay Facility fee (e.g., hospital room) $1,000 / admission Not covered Deductible applies first; pre- authorization / authorization required for certain services Physician/surgeon fees No charge Not covered Deductible applies first; pre- authorization / authorization required for certain services If you need mental health, behavioral health, or substance abuse services Outpatient services $50 / visit Not covered Deductible applies first; a telehealth cost share may be applicable; pre- authorization required for certain services Inpatient services $1,000 / admission Not covered Deductible applies first; pre- authorization / authorization required for certain services If you are pregnant Office visits No charge Not covered Deductible applies first except for prenatal care; cost sharing does not apply for 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 Not covered Childbirth/delivery facility services $1,000 / admission Not covered