Page 4 of 7 QP250022_L * For more information about limitations and exceptions, see the plan or policy document at www.phpni.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 help recovering or have other special health needs Home health care 20% coinsurance after deductible 50% coinsurance after deductible 100 visits/calendar year. Preauthorization is required to prevent claim denial. No coverage for private-duty nursing. Rehabilitation services 20% coinsurance after deductible 50% coinsurance after deductible Inpatient: 60 days/calendar year. Preauthorization is required to prevent claim denial. Outpatient Rehab: 40 visits/calendar year – PT, OT, ST. 36 visits/calendar year – Cardiac rehab. 20 visits/calendar year – Pulmonary rehab. Outpatient Habilitation: 40 visits/calendar year – PT, OT, ST. Habilitation services 20% coinsurance after deductible 50% coinsurance after deductible Skilled nursing care 20% coinsurance after deductible 50% coinsurance after deductible 30 days/calendar year. Preauthorization is required to prevent claim denial. Durable medical equipment 20% coinsurance after deductible 50% coinsurance after deductible For coverage of specific durable medical equipment, preauthorization is required to prevent claim denial. Hospice services 20% coinsurance after deductible Not covered 180 consecutive days/lifetime. Preauthorization is required to prevent claim denial.