Covered Medical Benefits Cost if you use an In-Network Provider Manipulation Therapy $20 copay per visit Coverage is limited to 20 visits per benefit period. Acupuncture $20 copay per visit Coverage is limited to 20 visits per benefit period. Other Services in an Office Allergy Testing $20 copay per visit Prescription Drugs Dispensed in the office 30% coinsurance Maximum of $250 member cost share per drug. Surgery $20 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 $100 copay per service Freestanding Radiology Center $100 copay per service Outpatient Hospital $100 copay per service Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply In-Network and Non-Network Providers: depending on the care provided. $20 copay per visit Page 2 of 9