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) (continued)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)