22 Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible $500 Copayment per admission then 40% Coinsurance after Deductible 50% Coinsurance after Deductible Hospital Transfers: If you are transferred between Facilities, only one Copayment will apply. You will not have to pay separate Copayments per Facility. Hospital Readmissions: If you are readmitted to the Hospital within 72 hours of your discharge for the same medical diagnosis, you will not have to pay an additional Copayment upon readmission. Doctor Services for: • General Medical Care/Evaluation and Management (E&M) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Surgery 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Maternity 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Mental Health / Substance Use Disorder Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% 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 The Office Visit Copayment will also apply to the first prenatal visit. 40% Coinsurance after Deductible The Office Visit Copayment will also apply to the first prenatal visit. 50% 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. 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.”