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) $1,000 maximum/day for Non- Emergency Admissions to Non- Network Providers. 20% Inpatient services 20% coinsurance 40% coinsurance coinsurance for Inpatient Physician Fee In-Network Providers. 40% coinsurance for Inpatient Physician Fee Non- Network Providers. Office visits $30/visit deductible does not 40% coinsurance $1,000 maximum/day for Non- apply Emergency Admissions to Non- Childbirth/delivery professional 20% coinsurance 40% coinsurance Network Providers. Maternity If you are services care may include tests and pregnant services described elsewhere in Childbirth/delivery facility the SBC (i.e., ultrasound). services 20% coinsurance 40% coinsurance *Coverage includes fertility preservation services, see Fertility Preservation section. Home health care 20% coinsurance 40% coinsurance 100 visits/benefit period. Rehabilitation services 20% coinsurance 40% coinsurance *See Therapy Services section. If you need help Habilitation services 20% coinsurance 40% coinsurance recovering or 150 days/benefit period for have other Skilled nursing care 20% coinsurance 40% coinsurance Inpatient rehabilitation and special health skilled nursing services needs combined. Durable medical equipment 20% coinsurance 40% coinsurance *See Durable Medical Equipment Section Hospice services No charge 40% coinsurance --------none-------- If your child Children’s eye exam No charge $0 copayment up to plan's needs dental or Maximum Allowed Amount *See Vision Services section eye care Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 4 of 12