t was a very long list. Too long to post. I posted the sections that had a copayment. The rest either said Not Covered or No Payment.

Out-of-pocket maximum Type Total family out-of-pocket maximum Total individual out-of-pocket maximum CA COMMON MOOP CAL $6,000.00 $3,000.00 CA COMMON MOOP CAL $6,000.00 $3,000.00

Professional Services (Plan Provider Office Visits) Pediatric Primary Care up to 5 years old 30.00 copay Primary Care 30.00 copay Provider Visits Primary Care Services Other Than E&M Codes 30.00 copay Specialty Care 30.00 copay Provider Visits Specialty Care services other than E&M codes 30.00 copay Provider Group Visit 15.00 copay Special Diagnostic Tests (e.g. EKG/EEG/ECHO, Ophthalmic tests, pulmonary function testing) 10.00 copay Special Diagnostic Tests (e.g. EKG/EEG/ECHO, Ophthalmic tests, pulmonary function testing) 10.00 copay

Ancillary Services (Imaging, Laboratory and Special Procedures) CT Scan 50.00 copay MRI scan 50.00 copay PET scan 50.00 copay

Therapy/Rehab Multidisciplinary Rehabilitation - Inpatient 500.00 unit Multidisciplinary Rehabilitation - Inpatient 500.00 unit Occupational Therapy Group Visit 15.00 copay Occupational Therapy Group Visit 15.00 copay Speech Therapy Group Visit 15.00 copay Occupational Therapy Visit 30.00 copay Physical Therapy Visit 30.00 copay Speech Therapy Visit 30.00 copay

Hospitalization Services Hospital Inpatient Care Transgender 500.00 unit Multidisciplinary Rehabilitation - Inpatient 500.00 unit Bariatric Surgery (Inpatient) 500.00 unit Inpatient Obstetrical Care and Delivery 500.00 unit Inpatient Psychiatric Care (Parity Dx) 500.00 unit Inpatient Psychiatric Care (Non-Parity Dx) 500.00 unit Inpatient Detoxification 500.00 unit Hospital Inpatient Care 500.00 unit

Emergency Health Coverage Emergency Department Observation Only 150.00 copay Urgent Care up to 5 years old 30.00 copay Emergency Care (waived if admitted) 150.00 copay Urgent Care 30.00 copay