Page 35 - USUI Benefit Book

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Information Limitations, Exceptions, & Other Important Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive. Preauthorization is required. Limited to a maximum of 50 visits per member, per calendar year. Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, Preauthorization is

Mileage limits apply. None Preauthorization may be required. None None Preauthorization is required. None None per calendar year. None required.

Out-of-Network Provider (You will pay the most) $200 copay/visit; deductible does Copay waived if admitted. $40 copay/visit; deductible does $250 copay/admission then 30% 30% coinsurance $250 copay/admission then 30% $250 copay/admission then 30% 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance

What You Will Pay not apply No charge not apply coinsurance 30% coinsurance coinsurance No charge; deductible does not 30% coinsurance 30% coinsurance coinsurance Not Covered

In-Network Provider (You will pay the least) $200 copay/visit; deductible does not apply No charge $40 copay/visit; deductible does not apply $125 copay/admission; deductible does not apply No charge $25 copay/visit; deductible does not apply $125 copay/admission; deductible does not apply apply No charge $125 copay/admission; deductible does not apply No charge No charge Not Covered No charge No charge

Services You May Need Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Outpatient services Inpatient services Office visits Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment

Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance use disorder services If you are pregnant If you need help recovering or have other special health needs