Covered Medical Benefits Cost if you use an In-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; $40 copay per visit usually found in major pharmacies or retail stores. Manipulation Therapy $40 copay per visit Coverage is limited to 20 visits per benefit period. Acupuncture $40 copay per visit Coverage is limited to 20 visits per benefit period. Other Services in an Office Allergy Testing $40 copay per visit Prescription Drugs Dispensed in the office 30% coinsurance Maximum of $250 member cost share per drug. Surgery $40 copay per surgery Preventive care / screenings / immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital No charge X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $125 copay per visit Freestanding Radiology Center $125 copay per visit Outpatient Hospital $125 copay per visit Page 2 of 9