provider charge. Specialty Provider Visit $40 copay/visit 35% Inpatient Physician Services 25% 35% Lab/Ancillary/Miscellaneous Charges 25% 35% Eye Exam (preventive & 0% 35% medical) one/year one/year $40 copay/visit for office visit only - lab, x-ray & Second Surgical Opinion 35% other procedures apply deductible/coinsurance Emergency Services Ambulance Services for Medical $200 copay *$200 copay Emergency *$250 copay/visit for $250 copay/visit room charges only lab, for room charges only x-ray & other Emergency Room Facility lab, x-ray & other procedures apply Charges procedures apply deductible/co- deductible/coinsurance insurance (waived if (waived if immediately immediately admitted to admitted to hospital) hospital) Professional Charges 25% 25% Urgent Care Services $75 copay/visit *$75 copay/visit for room charges only - for room charges only - Facility/Professional Charges lab, x-ray & other lab, x-ray & other procedures apply procedures apply deductible/coinsurance deductible/coinsurance Lab & Diagnostic Charges 25% 25% * Reminder: Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providers can balance bill the
provider charge. Specialty Provider Visit $40 copay/visit 35% Inpatient Physician Services 25% 35% Lab/Ancillary/Miscellaneous Charges 25% 35% Eye Exam (preventive & medical) 0% one/year 35% one/year Second Surgical Opinion $40 copay/visit for office visit only - lab, x-ray & other procedures apply deductible/coinsurance 35% Emergency Services Ambulance Services for Medical Emergency $200 copay *$200 copay Emergency Room Facility Charges $250 copay/visit for room charges only lab, x-ray & other procedures apply deductible/coinsurance (waived if immediately admitted to hospital) *$250 copay/visit for room charges only lab, x-ray & other procedures apply deductible/co- insurance (waived if immediately admitted to hospital) Professional Charges 25% 25% Urgent Care Services Facility/Professional Charges $75 copay/visit for room charges only - lab, x-ray & other procedures apply deductible/coinsurance *$75 copay/visit for room charges only - lab, x-ray & other procedures apply deductible/coinsurance Lab & Diagnostic Charges 25% 25% * Reminder: Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providers can balance bill the