Page 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* In-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 $35 copay/visit $105 copay/visit 90 visit limit - combination of network providers and out-of-network providers per person per plan year. Prior authorization is required for certain home health care services or there may be no coverage. Rehabilitation services $5 - $85 copay/visit Up to $220 copay/visit No visit limit for occupational therapy No visit limit for physical therapy No visit limit for speech therapy Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Habilitation services $5 - $85 copay/visit Up to $220 copay/visit Skilled nursing care $1,200 copay/stay $3,600 copay/stay 60 day limit per person per plan year. Prior authorization is required or there may be no coverage. Durable medical equipment $0 - $500 copay/equipment based on DME tier Up to $1,000 copay/equipment based on DME tier Prior authorization is required for certain DME or there may be no coverage. Hospice services Home: $35 copay/visit Inpatient: $1,600 copay/stay Home: $105 copay/visit Inpatient: $4,800 copay/stay None If your child needs dental or eye care Children’s eye exam Not covered Not covered None Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com.