Covered Services Your Cost Preventive Care Well-child care exams Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the maximum after deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services—office visits Nothing, no deductible Outpatient Care Emergency room visits $750 per visit after deductible (copayment waived if admitted or for observation stay) Office or health center visits, when performed by: • Your PCP, OB/GYN physician, nurse midwife, limited services clinic, or by a physician assistant or $50 per visit after deductible nurse practitioner designated as primary care • Other covered providers, including a physician assistant or nurse practitioner designated as $75 per visit after deductible specialty care Mental health or substance use treatment $50 per visit after deductible Outpatient telehealth services • With a covered provider Same as in-person visit • With the designated telehealth vendor $50 per visit after deductible Chiropractors’ office visits $75 per visit after deductible Acupuncture visits (up to 12 visits per calendar year) $75 per visit after deductible Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year*) $75 per visit after deductible Speech, hearing, and language disorder treatment—speech therapy $75 per visit after deductible Diagnostic X-rays and lab tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $1,000 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment—such as wheelchairs, crutches, hospital beds 20% coinsurance after deductible** Prosthetic devices 20% coinsurance after deductible Surgery and related anesthesia in an office or health center, when performed by: • Your PCP, OB/GYN physician, nurse midwife, or by a physician assistant or nurse practitioner $50 per visit*** after deductible designated as primary care • Other covered providers, including a physician assistant or nurse practitioner designated as $75 per visit*** after deductible specialty care Surgery and related anesthesia in an ambulatory surgical facility, hospital outpatient department, $1,000 per admission after deductible or surgical day care unit Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) $1,000 per admission after deductible Mental hospital or substance use facility care (as many days as medically necessary) $1,000 per admission after deductible Rehabilitation hospital care (up to 60 days per calendar year) $1,000 per admission after deductible Skilled nursing facility care (up to 100 days per calendar year) $1,000 per admission after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** Cost share waived for one breast pump per birth, including supplies. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate.