Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 6 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Skilled Nursing Care (facility) Coverage for Skilled Nursing, Outpatient Rehabilitation and Inpatient Rehabilitation facility settings is limited to 150 days combined per benefit period. 20% coinsurance after medical deductible is met $500 copay per admission and then 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Inpatient Hospice No charge No charge No charge Additional Services, Equipment and Devices Durable Medical Equipment 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prosthetic Devices 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Wigs Coverage for wigs is limited to 1 item after cancer treatment per benefit period. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Notes: • Dependent Age Limit: to the end of the month in which the child attains age 26. • Members are encouraged to always obtain prior approval when using Out-of-Network Providers. Precertification will help the member know if the services are considered not medically necessary. • No charge means no deductible / copayment / coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing an Out-of-Network Provider, the member is responsible for any balance due after the plan payment. • If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • ‡ You will pay your PCP or Specialist office visit copay for certain services provided in their office. • The representations of benefits in this document are subject to Indiana Department of Insurance (IN DOI) approval and are subject to change.