* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Preferred Network Provider (You will pay the least) In-Network Provider (You will pay more) 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 40% coinsurance 50% coinsurance 120 visits/benefit period for Home Health and Private Duty Nursing combined. Rehabilitation services $30/visit, deductible does not apply $80/visit, deductible does not apply 50% coinsurance *See Therapy Services section. Habilitation services $30/visit, deductible does not apply $80/visit, deductible does not apply 50% coinsurance Skilled nursing care 20% coinsurance $500/admission, then 40% coinsurance 50% coinsurance 150 days/benefit period for Inpatient physical medicine, rehabilitation including day rehabilitation programs and skilled nursing services combined. Durable medical equipment 20% coinsurance 40% coinsurance 50% coinsurance *See Durable Medical Equipment section. Hospice services No charge No charge No charge --------none-------- If your child needs dental or eye care Children’s eye exam Not covered Not covered Not covered --------none-------- Children’s glasses Not covered Not covered Not covered Children’s dental check-up Not covered Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services .) • Acupuncture • Cosmetic surgery • Glasses for a child • Long-term care • Weight loss programs • Bariatric surgery • Dental care (Adult) • Hearing aids • Routine eye care (Adult) • Children’s dental check-up • Eye exams for a child • Infertility treatment • Routine foot care unless medically necessary