Common What You Will Pay Limitations, Exceptions, & Medical Event Services You May Need In-Network Provider Non-Network Provider Other Important Information (You will pay the least) (You will pay the most) 150 days/benefit period for Inpatient rehabilitation and If you have a Facility fee (e.g., hospital room) $500/admission Not covered skilled nursing services hospital stay combined for In-Network Providers. Physician/surgeon fees No charge Not covered --------none-------- Office Visit Office Visit Office Visit 988 lifeline/mobile crisis team $20/visit Not covered covered as In-Network. Virtual If you need Outpatient services Other Outpatient Other Outpatient visits (Telehealth) benefits mental health, No charge Not covered available. behavioral health, Other Outpatient or substance --------none-------- abuse services No charge for Inpatient Physician Fee In-Network Inpatient services $500/admission Not covered Providers. No Coverage for Inpatient Physician Fee Non- Network Providers. Office visits $20/visit Not covered Maternity care may include tests Childbirth/delivery professional No charge Not covered and services described elsewhere If you are services in the SBC (i.e., ultrasound). pregnant Childbirth/delivery facility *Coverage includes fertility services $500/admission Not covered preservation services, see Fertility Preservation section. Home health care $20/visit Not covered 100 visits/benefit period for In- Network Providers. Rehabilitation services $20/visit Not covered *See Therapy Services section. If you need help Habilitation services $20/visit Not covered recovering or 150 days/benefit period for have other Inpatient rehabilitation and special health Skilled nursing care No charge Not covered skilled nursing services needs combined for In-Network Providers. Durable medical equipment 20% coinsurance Not covered *See Durable Medical Equipment Section Hospice services No charge Not covered --------none-------- If your child Children’s eye exam No charge Not covered *See Vision Services section * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 11