medical services for the year. 
Covered Medical and Hospital Benefits  
Acute inpatient hospital care $250 copay per day for days 1-7 
$0 copay per day for days 8-90 
Your plan covers an unlimited number of days for an inpatient stay. 
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital:  $250 copay 
•Outpatient surgery at Ambulatory Surgical Center:   $200 copay 
Doctor visits •Primary care provider:  $0 copay