Page 4 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 have outpatient surgery Facility fee (e.g., ambulatory surgery center) $15 - $2,500 copay/visit Up to $7,000 copay/visit 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. Prior authorization is required for certain outpatient surgery or there may be no coverage. Physician/surgeon fees No charge No charge If you need immediate medical attention Emergency room care $375 copay/visit $375 copay/visit Copay is waived if admitted within 24 hours. Out- of-network emergency room care visit copay applies to the in-network out-of-pocket limit. Emergency medical transportation $225 copay/transport $225 copay/transport Prior authorization is required for non-emergency medical transportation or there may be no coverage. Out-of-network emergency medical transportation copay applies to the in-network out- of-pocket limit. Urgent care $35 copay/visit $105 copay/visit None If you have a hospital stay Facility fee (e.g., hospital room) $200 - $2,500 copay/stay Up to $7,000 copay/stay 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. Prior authorization is required for non-emergency facility admissions and inpatient surgery or there may be no coverage. Physician/surgeon fees No charge No charge *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.