ACUTE INPATIENT HOSPITAL CARE 
N/A $500 copay per day for days 1-5 
$0 copay per day for days 6-90 
Your plan covers an unlimited 
number of days for an inpatient 
stay. $500 copay per day for days 1-5 
$0 copay per day for days 6-90 
OUTPATIENT HOSPITAL COVERAGE 
Outpatient surgery at 
outpatient hospital $300 copay $300 copay 
Outpatient surgery at 
ambulatory surgical center $250 copay $250 copay 
DOCTOR OFFICE VISITS 
Primary care provider (PCP) $0 copay $0 copay 
Specialists $30 copay $30 copay