* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 3 of 6 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) If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 10% coinsurance Other Outpatient 10% coinsurance Office Visit 30% coinsurance Other Outpatient 40% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services 10% coinsurance 30% coinsurance --------none-------- If you are pregnant Office visits 10% coinsurance 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services 10% coinsurance 30% coinsurance Childbirth/delivery facility services 10% coinsurance 30% coinsurance If you need help recovering or have other special health needs Home health care 10% coinsurance 30% coinsurance --------none-------- Rehabilitation services 10% coinsurance 30% coinsurance *See Therapy Services section. Habilitation services 10% coinsurance 30% coinsurance Skilled nursing care 10% coinsurance 30% coinsurance 120 days/benefit period for skilled nursing services. Durable medical equipment 10% coinsurance 40% coinsurance *See Durable Medical Equipment section. Hospice services 10% coinsurance 30% coinsurance Life expectancy up to 12 months. If your child needs dental or eye care Children’s eye exam Not covered Not covered --------none-------- Children’s glasses Not covered Not covered Children’s dental check-up 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 • Dental care (Adult) • Hearing aids • Routine eye care (Adult) • Children’s dental check-up • Eye exams for a child • Infertility treatment • Routine foot care unless medically necessary • Cosmetic surgery • Glasses for a child • Long-term care • Weight loss programs