Page 3 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition Tier 1 - Your Lowest Cost Option Not Covered Not Covered No coverage for prescription drugs with UnitedHealthcare. Tier 2 - Your Mid- Range Cost Option Not Covered Not Covered Tier 3 - Your Mid- Range Cost Option Not Covered Not Covered Tier 4 - Your Highest Cost Option Not Applicable Not Applicable If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount. Physician/ surgeon fees 0% coinsurance 30% coinsurance None If you need immediate medical attention Emergency room care 0% coinsurance *0% coinsurance *Network deductible applies. Emergency medical transportation 0% coinsurance *0% coinsurance *Network deductible applies. Urgent Care 0% coinsurance 30% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) 0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. Physician/ surgeon fees 0% coinsurance 30% coinsurance None