26 Approved In-Network Provider All Other Providers Covered Procedure Benefit Period The number of days or the applicable case rate / global time period will vary depending on the type of Covered Procedure and the Approved In-Network Provider agreement. Before and after the Covered Procedure Benefit Period, Covered Services will be covered as Inpatient Services, Outpatient Services, Home Visits, or Office Visits depending on where the service is performed. Not applicable – There is no unique Benefit Period for services from All Other Providers Inpatient Facility Services • Precertification required 20% Coinsurance after Deductible 40% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Inpatient Professional and Ancillary (non-Hospital) Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Outpatient Facility Services • Precertification required 20% Coinsurance after Deductible 40% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Outpatient Facility Professional and Ancillary (non-Hospital) Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit.