Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services Home/Office: $10 copay/visit Outpatient Facility: $75 copay/visit Home/Office: $100 copay/visit Outpatient Facility: $225 copay/visit Certain procedures/services in the outpatient setting may have a lower copay. Prior authorization is required for certain outpatient services or there may be no coverage. Inpatient services $1,200 copay/stay $3,600 copay/stay Certain procedures/services in the inpatient setting may have a lower copay. Prior authorization is required for certain inpatient services or there may be no coverage. If you are pregnant Office visits No charge $100 copay/visit Cost sharing does not apply to preventive services with network providers. Depending on the type of service, a copay may apply. Childbirth/delivery professional services No charge No charge One copay for all covered services related to childbirth/delivery, including the newborn, unless discharged after mother. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Cost sharing does not apply to certain preventive services. Prior authorization is required for inpatient stays beyond 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery or there may be no coverage. Childbirth/delivery facility services $625 - $1,600 copay/stay $4,800 copay/stay