• Advanced 20% Coinsurance after Deductible Diagnostic Imaging (including MRIs, CAT scans) As described in the “Consolidated Appropriations Act of 2021 Notice” at the front of this Booklet, for Emergency Services, Out-of-Network Providers may only bill you for any applicable Copayments, Deductible and Coinsurance and may not bill you for any charges over the Plan’s Maximum Allowed Amount until the treating Out-of-Network Provider has determined you are stable and followed the notice and consent process. Please refer to the Notice at the beginning of this Booklet for more details. Habilitative Services Benefits are based on the setting in which Covered Services are received. See “Therapy Services” for details on Benefit Maximums. Home Health Care • Home Health Care 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Visits from a Home Deductible Deductible Deductible Health Care Agency (Including intermittent skilled nursing services) • Home Dialysis 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Home Infusion 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Therapy / Deductible Deductible Deductible Chemotherapy • Specialty 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Prescription Drugs Deductible Deductible Deductible for Infusion / Injection – Other than Chemotherapy • Other Home Health 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Care Services / Deductible Deductible Deductible Supplies • Private Duty 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Nursing (Including Deductible Deductible Deductible continuous complex skilled nursing services) • Home Health Care 120 visits per Benefit Period, In- and Out-of-Network combined Benefit Maximum The limit includes Private Duty Nursing and Therapy Services (e.g., physical, speech, occupational, cardiac and pulmonary rehabilitation) given as part of the Home Care benefit. The limit does not apply to Home Infusion Therapy or Home Dialysis. 19