v1.0 3 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you need mental health, behavioral health or substance abuse services Outpatient services— Office visit $25 copay/visit; deductible waived Not covered Preauthorization required for Intensive outpatient treatment & Inpatient services Inpatient services deductible only Not covered If you are pregnant Office visits No charge; deductible waived Not covered Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) Childbirth/delivery professional services deductible only Not covered Childbirth/delivery facility services deductible only Not covered If you need help recovering or have other special health needs Home health care deductible only Not covered Preauthorization required. Rehabilitation services— Inpatient Outpatient deductible only Physical therapy: $25 copay/visit; deductible waived Not covered 60 days/yr. Preauthorization required for Inpatient & Speech therapy. Coverage is limited to an annual max of 20 visits for Physical therapy and 20 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies Habilitation services Physical therapy: $25 copay/visit; deductible waived Hearing, Occupational, & Speech therapies: $25 copay/visit; deductible waived Not covered Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies When covered under the plan, early intervention services are covered until