Page 5 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 you need help recovering or have other special health needs Home health care No charge Not covered Deductible applies first; pre- authorization required for certain services Rehabilitation services $75 / visit for outpatient services; $1,000 / admission for inpatient services Not covered Deductible applies first; limited to 60 outpatient visits per calendar year (other than for autism, home health care, and speech therapy); limited to 60 days per calendar year for inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Habilitation services $75 / visit Not covered Deductible applies first; outpatient rehabilitation therapy coverage limits apply; copayment and coverage limits waived for early intervention services for eligible children; a telehealth cost share may be applicable; pre- authorization required for certain services Skilled nursing care $1,000 / admission Not covered Deductible applies first; limited to 100 days per calendar year; pre- authorization required Durable medical equipment 20% coinsurance Not covered Deductible applies first; cost share waived for one breast pump per birth, including supplies Hospice services No charge Not covered Deductible applies first; pre- authorization required for certain services If your child needs dental or eye care Children’s eye exam No charge Not covered Limited to one exam every 24 months Children’s glasses Not covered Not covered None Children’s dental check-up No charge for members with a cleft palate / cleft lip condition Not covered Limited to members under age 18