19 Benefits • Residential Treatment Center 20% Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible Doctor Services when billed separately from the Facility for: • General Medical Care / Evaluation and Management (E&M) 20% Coinsurance after Deductible • Surgery 20% Coinsurance after Deductible • Maternity 20% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services 20% Coinsurance after Deductible Maternity and Reproductive Health Services • Maternity Visits (Global fee for the ObGyn’s prenatal, postnatal, and delivery services) 20% Coinsurance after Deductible • Inpatient Facility Services (Delivery) See “Inpatient Services” Newborn / Maternity Stays: If the newborn needs services other than routine nursery care or stays in the Hospital after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission. • Infertility Services 20% Coinsurance after Deductible Mental Health and Substance Use Disorder Services Mental Health and Substance Use Disorder Services are covered as required by state and federal law. Please see the rest of this Schedule for the cost shares that apply in each setting. Occupational Therapy See “Therapy Services.” Office and Home* Visits *Home visits are not the same as Home Health Care. For Home Health Care benefits please see the "Home Health Care" section. Important Note on Office Visits at an Outpatient Facility: If you have an office visit with your PCP or SCP at an Outpatient Facility (e.g., Hospital or Ambulatory Surgery Center), benefits for Covered Services will be paid under the “Outpatient Facility Services” section later in this Schedule. Please refer to that section for details on the cost shares (e.g., Deductibles, Copayments, Coinsurance) that will apply. • Primary Care Physician / Provider (PCP) (Including In-Person and/or Virtual Visits) Includes Ob/Gyn 20% Coinsurance after Deductible