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 Mental Health and Substance Use Disorder Services are covered as required Substance Use by state and federal law. Please see the rest of this Schedule for the cost Disorder Services 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 In-Person Visits: In-Person Visits: 50% Coinsurance after Physician / Provider Deductible (PCP) Includes $15 Copayment per visit $40 Copayment per visit Ob/Gyn (Including In-Person and/or Virtual Visits: Virtual Visits: Virtual Visits) $15 Copayment per visit $40 Copayment per visit • Additional $15 Copayment per visit $40 Copayment per visit 50% Coinsurance after Telehealth/Telemed Deductible icine Services from a Primary Care Provider (PCP) (as required by law) • Mental Health and In-Person Visits: In-Person Visits: 50% Coinsurance after Substance Use Deductible Disorder Provider $15 Copayment per visit $40 Copayment per visit (Including In- Person and/or Virtual Visits: Virtual Visits: Virtual Visits) $15 Copayment per visit $40 Copayment per visit • Specialty Care In-Person Visits: In-Person Visits: 50% Coinsurance after Physician / Provider Deductible (SCP) (including In- $30 Copayment per visit $80 Copayment per visit Person and/or Virtual Visits) Virtual Visits: Virtual Visits: $30 Copayment per visit $80 Copayment per visit • Additional $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Telehealth/Telemed Deductible 22