Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) other special health Outpatient: $30 / visit Combined with Habilitation services: needs Rehabilitation services Inpatient: $150 / day up to Not covered Outpatient: 60 visit limit / year. Inpatient: 60- $750 / admission day limit / year, preauthorization required or will not be covered. Outpatient: $30 / visit Combined with Rehabilitation services: Habilitation services Inpatient: $150 / day up to Not covered Outpatient: 60 visit limit / year. Inpatient: 60- $750 / admission day limit / year, preauthorization required or will not be covered. Skilled nursing care $150 / day up to $750 / Not covered 150-day limit / year. Preauthorization admission required or will not be covered. Durable medical 20% coinsurance, Subject to formulary guidelines. equipment deductible does not apply. Not covered Preauthorization required or will not be covered. Hospice services No charge, deductible does Not covered Preauthorization required or will not be not apply. covered. Children’s eye exam $15 / visit for refractive Not covered Limited to 1 exam / 12 months exam Members age 19 and over limited to $150 If your child needs every 24 months. Members under age 19 dental or eye care Children’s glasses No charge Not covered limited to 1 pair of frames and lenses / year or contact lenses covered at 50% coinsurance. Children’s dental check- Not covered Not covered None up 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.) • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Routine foot care • Infertility treatment • Private-duty nursing • Weight loss programs • Long-term care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (24 visit limit / year) • Chiropractic care (24 visit limit / year) • Routine eye care (Adult) • Bariatric surgery • Hearing aids ($3,000 limit / ear / 36 months) Page 4 of 6