Page 4 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information 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 0% coinsurance 30% coinsurance Network All Other: 0% coinsurance. See your policy or plan document for additional information about Employee Assistance Program (EAP) benefits. Inpatient services 0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. See your policy or plan document for additional information about EAP benefits. If you are pregnant Office Visits No Charge 30% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery professional services 0% coinsurance 30% coinsurance Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery facility services 0% coinsurance 30% coinsurance Inpatient Preauthorization applies out-of-network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to 50% of allowed amount. If you need help recovering or have other special health needs Home health care 0% coinsurance 30% coinsurance Limited to 90 visits per calendar year. Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount. Rehabilitation services 0% coinsurance 30% coinsurance Limits per calendar year: Cardiac: 36 visits; Physical, Occupational, Speech, Pulmonary: Unlimited. Habilitative services 0% coinsurance 30% coinsurance Services are provided under Rehabilitation Services above. Skilled nursing care 0% coinsurance 30% coinsurance Limited to 60 days per calendar year (combined with inpatient rehabilitation). Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.