What You Will Pay Preferred In-Network Out-of-Network Common Services You May Need Network Provider Provider Limitations, Exceptions, & Medical Event Provider (You will pay (You will pay the Other Important Information (You will pay the more) most) least) special health Habilitation services $30/visit $80/visit, then 20% 50% coinsurance needs coinsurance $500/admission, 100 days/benefit period for Skilled nursing care 0% coinsurance then 20% 50% coinsurance skilled nursing services. coinsurance Durable medical equipment 0% coinsurance 20% coinsurance 50% coinsurance *See Durable Medical Equipment section. Hospice services 0% coinsurance 20% coinsurance 50% coinsurance --------none-------- If your child Children’s eye exam Not covered Not covered Not covered --------none-------- needs dental or Children’s glasses Not covered Not covered Not covered eye care 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 • Bariatric surgery • Children’s dental check-up • Cosmetic surgery • Dental care (Adult) • Eye exams for a child • Glasses for a child • Hearing aids • Infertility treatment • Long-term care • Routine eye care (Adult) • Routine foot care unless medically necessary • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care 12 visits/benefit period • Most coverage provided outside the United • Private-duty nursing 82 visits/year and 164 States. See www.bcbsglobalcore.com visits/lifetime Facility Setting only Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395, www.in.gov/idoi/3008.htm, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 4 of 11