Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) 20% coinsurance for all other services Inpatient services 20% coinsurance 40% coinsurance None Office visits 20% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 20% coinsurance 40% coinsurance Depending on the type of services, a copayment, If you are pregnant professional services coinsurance or deductible may apply. Maternity care Childbirth/delivery 20% coinsurance 40% coinsurance may include tests and services described elsewhere in facility services the SBC (i.e. ultrasound). Home health care 20% coinsurance 40% coinsurance 130 visits / year 30 inpatient days / year $30 copay / outpatient visit, 30 outpatient visits / year deductible does not apply; Copayment applies to each in-network provider Rehabilitation services 40% coinsurance outpatient visit only. All inpatient services are covered 20% coinsurance for at the coinsurance specified, after deductible. inpatient services Includes physical therapy, occupational therapy and If you need help speech therapy. recovering or have 30 neurodevelopmental visits / year other special health Neurodevelopmental therapy limited to individuals needs $30 copay / visit, deductible under age 18. Habilitation services does not apply 40% coinsurance Copayment applies to each in-network provider visit only. Includes physical therapy, occupational therapy and speech therapy. Skilled nursing care 20% coinsurance 40% coinsurance 60 inpatient days / year Durable medical 20% coinsurance 40% coinsurance None equipment Hospice services 20% coinsurance 40% coinsurance 14 respite inpatient or outpatient days / lifetime Children's eye exam Not covered Not covered If your child needs Children's glasses Not covered Not covered None dental or eye care Children's dental check- Not covered Not covered up Page 5 of 7