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<br /> <br /> <br /> 4 of 6 <br /> <br />Common <br />Medical Event <br />Services You May Need <br />What You Will Pay <br />Limitations, Exceptions, and Other Important <br />Information <br />Network Provider <br />(You will pay the <br />least) <br />Out-of-Network <br />Provider <br />(You will pay the <br />most) <br />If you need mental health, <br />behavioral health, or <br />substance abuse needs <br />Inpatient services 0% coinsurance 50% coinsurance None <br />If you are pregnant <br />Office visits No charge 50% coinsurance Depending on the type of services, a copayment, <br />coinsurance, or deductible may apply. <br />Childbirth/delivery <br />professional services 0% coinsurance 50% coinsurance None <br />Childbirth/delivery facility <br />services 0% coinsurance 50% coinsurance None <br />If you need help recovering <br />or have other special health <br />needs <br />Home health care 0% coinsurance 50% coinsurance 120 visits per calendar year <br />Rehabilitation services 0% coinsurance 50% coinsurance None <br />Habilitation services 0% coinsurance 50% coinsurance None <br />Skilled nursing care 0% coinsurance 50% coinsurance 120 days per calendar year <br />Durable medical <br />equipment 0% coinsurance 50% coinsurance None <br />Hospice services 0% coinsurance 50% coinsurance <br />Respite care is limited to 5 days per episode and <br />respite care and continuous care combined are <br />limited to 30 days per episode . <br />If your child needs dental or <br />eye care <br />Children’s eye exam No charge 50% coinsurance None <br />Children’s glasses 0% coinsurance Not covered <br />Limited to one pair of eyeglasses (lenses and <br />frames) or one pair of contact lenses per <br />calendar year. <br />Children’s dental check -up No charge 50% coinsurance None