v1.0 4 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 help recovering or have other special health needs (continued) age 3 and plan limits and precertification requirements apply to coverage for developmental delays Skilled nursing care deductible only Not covered 60 days/yr. Preauthorization required Durable medical equipment deductible only Not covered Preauthorization required for rental over 3 months, equipment over $1,000, neuromuscular stimulator equipment & implantable loop recorders/defibrillators Hospice services deductible only Not covered Preauthorization required If your child needs dental or eye care Children’s eye exam Not covered Not covered n/a Children’s glasses Not covered Not covered n/a Children’s dental check-up Not covered Not covered n/a 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.) • Cosmetic surgery • Non-emergency care when traveling outside U.S. • Routine foot care • Dental care (routine over age 13) • Private duty nursing • Weight loss programs • Long term care • Routine eye care (adult & child) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (20 visits/yr) • Hearing aids (1/aid/ear/3 yrs/up to $2,500/ear; 1 bone anchored hearing aid/lifetime up to age 18) • Bariatric Surgery ($50,000 lifetime max) • Infertility treatment ($30,000 Rx/lifetime & $50,000 medical/lifetime) • Chiropractic care (20 visits/yr) • Wigs (1 wig/yr when related to cancer, surgery, burns, or alopecia, up to $500)