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6 332 <br />In-Network Out-of-Network <br />Emergency <br />Medicare-Covered Emergency Care <br />Care <br />■ $75 copay per visit, in- or out-of-network <br />This copay is waived if you are admitted to the hospital within 48 hours of an <br />emergency room visit. <br />Worldwide Emergency Care Services <br />■ $75 copay for Worldwide Emergency Care <br />■ $25,000 combined yearly limit for Worldwide Emergency Care and Worldwide <br />Urgently Needed Services <br />Does not include emergency transportation. <br />Urgently <br />Medicare-Covered Urgently Needed Services <br />Needed <br />Urgently needed services are provided to treat a non-emergency, unforeseen <br />Services <br />medical illness, injury, or condition that requires immediate medical attention. <br />■ $30 copay at an Urgent Care Center, in- or out-of-network <br />Convenient Care Services are outpatient services for non-emergency injuries and <br />illnesses that need treatment when most family physician offices are closed. <br />■ $30 copay at a Convenient Care Center, in- or out-of-network <br />Worldwide Urgently Needed Services <br />■ $75 copay for Worldwide Urgently Needed Services <br />■ $25,000 combined yearly limit for Worldwide Emergency Care and Worldwide <br />Urgently Needed Services <br />Does not include emergency transportation. <br />6 332 <br />