Page 5 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) Durable medical equipment 20% coinsurance 40% coinsurance Preauthorization is required out-of-network for DME over $1,000 or no coverage. Hospice services 20% coinsurance 40% coinsurance Preauthorization is required out-of-network before admission for an Inpatient Stay in a hospice facility or benefit reduces to 50% of allowed amount. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exams. Children’s glasses Not Covered Not Covered No coverage for Children’s glasses. Children’s dental check-up Not Covered Not Covered No coverage for Children’s dental check-up.