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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 Need What You Will PayLimitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider(You will pay the most) 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. Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. Ultrasound). Not covered - for child. Childbirth/delivery professional services 20% Coinsurance for Inpatient Hospital. Not Covered. Not covered - for child. Childbirth/delivery facility services 20% Coinsurance for Inpatient Hospital. Not Covered. Not covered - for child. In-network inpatient separation period is limited to 90 days. If you need help recovering or haveother special health needsHome health care 20% Coinsurance. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. Rehabilitation services 20% Coinsurance for Inpatient Hospital. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. Coverage is limited to Habilitation services 20% Coinsurance for 60 days. Inpatient Hospital. Not Covered. Skilled nursing care 20% 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 20% 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 examvisit limitis 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__________29