What You Will Pay Common Preferred In-Network Out-of-Network Limitations, Exceptions, & Medical Event Services You May Need Network Provider Provider Provider Other Important Information (You will pay the (You will pay (You will pay the least) more) most) $500/admission, 100 days/benefit period for Skilled nursing care 0% coinsurance then 20% 50% coinsurance skilled nursing services. coinsurance Durable medical equipment 0% coinsurance 20% coinsurance 50% coinsurance *See Durable Medical Equipment section. Hospice services 0% coinsurance 20% coinsurance 50% coinsurance --------none-------- If your child Children’s eye exam Not covered Not covered Not covered --------none-------- needs dental or Children’s glasses Not covered Not covered Not covered eye care Children’s dental check-up Not covered Not covered Not covered --------none-------- 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.) • Acupuncture • Bariatric surgery • Children’s dental check-up • Cosmetic surgery • Dental care (Adult) • Eye exams for a child • Glasses for a child • Hearing aids • Infertility treatment • Long-term care • Routine eye care (Adult) • Routine foot care unless medically necessary • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care 12 visits/benefit period • Most coverage provided outside the United • Private-duty nursing 82 visits/year and 164 States. See www.bcbsglobalcore.com visits/lifetime Facility Setting only Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395, www.in.gov/idoi/3008.htm, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 4 of 11