Page 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If your child needs dental or eye care Childrens eye exam No charge 20% coinsurance Deductible applies first for out-of- network; limited to one exam every 24 months Childrens glasses Not covered Not covered None Childrens dental check-up No charge for members with a cleft palate / cleft lip condition 20% coinsurance for members with a cleft palate / cleft lip condition Deductible applies first for out-of- network; limited to members under age 18 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Children's glasses Cosmetic surgery Dental care (Adult) Long - term care Private - duty nursing Other Covered Services (Limitations may apply to these services. This isnt a complete list. Please see your plan document.) Acupuncture (12 visits per calendar year) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 or younger) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care - adult (one exam every 24 months) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy)