Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Inpatient services 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses. Office visits 30% coinsurance 50% coinsurance Childbirth/delivery professional services 30% coinsurance 50% coinsurance If you are pregnant Childbirth/delivery facility services 30% coinsurance 50% coinsurance Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Home health care 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Rehabilitation services 30% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy 30% coinsurance/visit for Chiropractic care 50% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy 50% coinsurance/visit for Chiropractic care Coverage is limited to an annual max of 60 visits for Physical therapy, Speech, Hearing & Occupational therapy and 30 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. If you need help recovering or have other special health needs Habilitation services 30% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy 50% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.