v1.0 3 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you need mental health, behavioral health or substance abuse services Outpatient services— Office visit $25 copay/visit; deductible waived 20% coinsurance Preauthorization required for Intensive outpatient treatment & Inpatient services Inpatient services deductible only 20% coinsurance If you are pregnant Office visits No charge; deductible waived 20% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) Childbirth/delivery professional services deductible only 20% coinsurance Childbirth/delivery facility services deductible only 20% coinsurance If you need help recovering or have other special health needs Home health care deductible only 20% coinsurance Preauthorization required. Rehabilitation services— Inpatient Outpatient deductible only $25 copay/visit; deductible waived 20% coinsurance 60 days/yr. Preauthorization required for Inpatient & Speech therapy. $500 penalty for failure to precertify out-of-network speech therapy. Coverage is limited to an annual max of 20 visits for Physical therapy and 20 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies Habilitation services Physical therapy: $25 copay/visit; deductible waived 20% coinsurance Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality.