What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Home health care No charge 20% coinsurance Deductible applies first; pre- authorization required Deductible applies first; limited to 60 outpatient visits per calendar year $60 / visit for 20% coinsurance for (other than for autism, home health outpatient services; outpatient services; care, and speech therapy); limited to Rehabilitation services $1,000 / admission 20% coinsurance for 60 days per calendar year for for inpatient services inpatient services inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Deductible applies first; outpatient If you need help recovering rehabilitation therapy coverage limits or have other special health Habilitation services $60 / visit 20% coinsurance apply; copayment and coverage limits needs waived for early intervention services for eligible children; a telehealth cost share may be applicable Deductible applies first; limited to 100 Skilled nursing care $1,000 / admission 20% coinsurance days per calendar year; pre- authorization required Deductible applies first; in-network Durable medical equipment 20% coinsurance 40% coinsurance cost share waived for one breast pump per birth, including supplies (20% coinsurance for out-of-network) Deductible applies first; pre- Hospice services No charge 20% coinsurance authorization required for certain services Children’s eye exam No charge 20% coinsurance Limited to one exam every 24 months Children’s glasses Not covered Not covered None If your child needs dental No charge for 20% coinsurance for or eye care Children’s dental check-up members with a cleft members with a cleft Limited to members under age 18 palate / cleft lip palate / cleft lip condition condition Page 5 of 8