9 Outpatient Hospital/ Facility–Diagnostic Services, Pre-admission testing Outpatient Professional Services Labs and X-Ray Surgery Maternity Benefits Hospitalization Birthing Center Professional— Pre & Postnatal Care Newborn Pediatric Inpatient Care Infertility Services Infertility Counseling and Testing Artificial Insemination In Vitro Fertilization Mental Health & Substance Abuse Benefits-Inpatient Professional Mental Health & Substance Abuse Benefits-Outpatient Professional Emergency & Urgent Care—In Area In Office Urgent Care Center Plan Affiliated Emergency Room Ambulance – Ground and Air Plan Benefits Covered at 100%. Diagnostic Lab and X-Ray covered at 100%. Profes- sional services covered at 100%. Outpatient hospital covered at 100%. Professional services covered at 100%. Covered at 100%. Covered at 100%. Covered at 100% after the first visit to applicable PCP. Nursery care covered at 100%. Covered at 100%. Covered at 100% after appli- cable PCP or specialist copay; limit of 3 attempts per live birth; not to exceed lifetime combined limit $100,000. Covered at 100%. Covered at 100% after $20 copay. Covered at 100% after $25 copay. $150 copay for ER; waived if admitted. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS In-Network Covered at 100%. Diagnostic Lab and X-Ray covered at 100%. Profes- sional services covered at 100%. Outpatient hospital covered at 100%. Professional services covered at 100%. Covered at 100%. Covered at 100%. Covered at 100% after the first visit to applicable PCP. Nursery care covered at 100%. Covered at 100%. Covered at 100% after applicable PCP or specialist copay; limit of 3 attempts per live birth; not to exceed lifetime limit $100,000. Covered at 100%. Covered at 100% after $20 copay. Covered at 100% after $20 copay. $150 copay for ER; waived if admitted. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Select EPO In-Network Only Covered at 100%. Covered at 100%. (Outpatient Specialty Imaging $50 copay) $25 copay. Covered at 100%. Covered at 100% if Kaiser authorized. $25 copay for initial visit, then covered at 100%. Covered at 100%. 50% of allowable charges. 50% of allowable charges for up to 3 attempts per live birth. Not to exceed lifetime limit of $100,000. Covered at 100%. Copays: $20 Individual and $10 group therapy. $25 copay. $150 copay for emergency room; waived if admitted. $50 copay. Kaiser Permanente HMO In-Network Only 2018 Non-Medicare Medical Summary of Services SUMMARY OF SERVICES DISCLAIMER This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure, the plan brochure will govern. PLEASE NOTE: Copay (copayment) charges are PER VISIT unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 19–23 for Medicare Supplement Plan details. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible; Limit of 3 attempts per live birth; not to exceed lifetime combined limit $100,000. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 100% after $25 copay. Covered at the network level. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS Out-of-Network