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* For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/members. 4 of 8Common Medical Event Services You May NeedWhat You Will PayLimitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider(You will pay the most) limited to 90 days. If you are pregnant Office visits $20.00 Copayment per visit for Office. $40.00 Copayment per visit for Specialist. Deductible does not apply. Not Covered. Not covered - for child. Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. Ultrasound). Childbirth/delivery professional services 30% Coinsurance for Inpatient Hospital. Not Covered. Not covered - for child. Childbirth/delivery facility services 30% Coinsurance for Inpatient Hospital. Not Covered. Not covered - for child. In-network & Outof-network inpatient separation period is limited to 90 days. If you need help recovering or haveother special health needsHome health care 30% Coinsurance. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. Rehabilitation services 30% Coinsurance for Inpatient Hospital. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. Coverage is limited to Habilitation services 30% Coinsurance for 60 days. Inpatient Hospital. Not Covered. Skilled nursing care 30% Coinsurance for Inpatient Facility. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. In-network inpatient skilled nursing facility day limit is limited to 100 days. Durable medical equipment 50% Coinsurance. Deductible does not apply.Not Covered. Prior authorization required for DME purchases over $500. 20% penalty applies for non-compliance. Hospice services 30% Coinsurance for Inpatient Facility. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. If your child needsdental or eye care$40.00 Copayment for Specialist. Deductible does not apply. Not Covered. In-network routine vision exam visit limit is limited to 1 visit. $100.00 Reimbursement. Deductible does not apply.Not Covered. In-network routine vision hardware dollar limit coverage is limited to every 2 years. -up Not Covered. Not Covered. __________none__________21