Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 4 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Outpatient Surgery Facility Fees Hospital 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met $250 copay per visit and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Ambulatory Surgical Center 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical 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 medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Human Organ and Tissue Transplants Cornea transplants are treated as medical procedures, with benefits and cost sharing determined by the setting in which the services are received. No charge No charge 50% coinsurance after medical deductible is met Physician and other services including surgeon fees 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Home Health Care Coverage is limited to 120 visits per benefit period. Limits are combined for all home health services. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Therapy Services