* For more information about limitations and exceptions, see the plan or policy document at www.myevhc.com. 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Provider (You will pay the least) Nonpreferred Provider (You will pay the most) If you need help recovering or have other special health needs Home health care $25 copayment (deductible does not apply) Not covered Home health care visits limited to 100 visits per benefit period. Pre- certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. Rehabilitation services $25 copayment/visit (deductible does not apply) Not covered None. Habilitation services $25 copayment/visit (deductible does not apply) Not covered None. Skilled nursing care 30% coinsurance Not covered Skilled nursing care limited to 100 days per benefit period. Pre- certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. Durable medical equipment $70 copayment/procedure (deductible does not apply) Not covered None. Hospice services Inpatient: 30% coinsurance Outpatient: 0% coinsurance (deductible does not apply) Not covered Pre-certification is required. If pre- certification is not obtained, benefits are subject to a $300 penalty of the total cost of the service. If your child needs dental or eye care Children’s eye exam $25 copayment/visit (deductible does not apply) Not covered Limited to 1 exam per benefit period. Children’s glasses Not covered Not covered None. Children’s dental check-up Not covered Not covered None.