Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
EMERGENCY CARE 
Emergency room 
If you are admitted to the 
hospital within 24 hours, you do 
not have to pay your share of the 
cost for the emergency care. $125 copay $125 copay 
Urgently needed services 
Urgently needed services are 
provided to treat a 
non-emergency, unforeseen 
medical illness, injury or condition 
that requires immediate medical 
attention. $35 copay at an urgent care 
center $35 copay at an urgent care 
center