ACUTE INPATIENT HOSPITAL CARE 
N/A $750 copay per admit 
Your plan covers an unlimited 
number of days for an inpatient 
stay. 30% of the cost 
OUTPATIENT HOSPITAL COVERAGE 
Outpatient surgery at 
outpatient hospital $390 copay 30% of the cost 
Outpatient surgery at 
ambulatory surgical center $250 copay 30% of the cost 
DOCTOR OFFICE VISITS 
Primary care provider (PCP) $10 copay 30% of the cost 
Specialists $40 copay 30% of the cost 
PREVENTIVE CARE 
N/A Our plan covers many preventive