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) Office visits $30/visit deductible does not Not covered Maternity care may include tests apply and services described elsewhere If you are Childbirth/delivery professional No charge Not covered in the SBC (i.e., ultrasound). pregnant services *Coverage includes fertility Childbirth/delivery facility 25% coinsurance Not covered preservation services, see services Fertility Preservation section. Home health care $30/visit deductible does not Not covered 100 visits/benefit period for In- apply Network Providers. Rehabilitation services $30/visit deductible does not Not covered apply *See Therapy Services section. If you need help Habilitation services $30/visit deductible does not Not covered recovering or apply have other 150 days/benefit period for special health Inpatient rehabilitation and needs Skilled nursing care 25% coinsurance Not covered skilled nursing services combined for In-Network Providers. Durable medical equipment 20% coinsurance deductible Not covered *See Durable Medical does not apply Equipment Section Hospice services No charge Not covered --------none-------- If your child Children’s eye exam No charge Not covered *See Vision Services section needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered --------none-------- 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.)  Children’s dental check-up  Cosmetic surgery  Dental care (Adult)  Glasses for a child  Hearing aids  Infertility treatment  Long-term care  Non-emergency care when traveling outside  Routine foot care unless you have been  Weight loss programs the U.S. diagnosed with diabetes Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Acupuncture 20 visits/benefit period  Bariatric surgery  Chiropractic care 20 visits/benefit period * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 4 of 11