* 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 30% coinsurance 50% coinsurance 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) 50% coinsurance Physical therapy and occupational therapy not covered for nonpreferred provider. Habilitation services $25 copayment/visit (deductible does not apply) 50% coinsurance Skilled nursing care 30% coinsurance 50% coinsurance 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 30% coinsurance Not covered None. Hospice services 30% coinsurance 50% coinsurance 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 every 24 months. Children’s glasses Not covered Not covered None. Children’s dental check-up Not covered Not covered None.