Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Ambulatory Surgical Center 20% coinsurance after $250 copay per visit 50% coinsurance after deductible is met and then 40% deductible is met coinsurance after deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Ambulatory Surgical Center 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees 20% coinsurance after $500 copay per 50% coinsurance after deductible is met admission and then deductible is met 40% coinsurance after deductible is met Human Organ and Tissue Transplants No charge No charge 50% coinsurance after Cornea transplants are treated the same as any deductible is met other illness and subject to the medical benefits. Physician and other services including 20% coinsurance after 40% coinsurance after 50% coinsurance after surgeon fees deductible is met deductible is met deductible is met Home Health Care 20% coinsurance after 40% coinsurance after 50% coinsurance after Coverage is limited to 120 visits per benefit deductible is met deductible is met deductible is met period. Limits are combined for all home health services. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Page 4 of 10