Cost if you use an In- Cost if you use a Covered Medical Benefits Network Provider Non-Network Provider Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) $30 copay per visit 40% coinsurance after medical deductible medical deductible is does not apply met Retail Health Clinic for routine care and treatment of common illnesses; $30 copay per visit 40% coinsurance after usually found in major pharmacies or retail stores. medical deductible medical deductible is does not apply met Manipulation Therapy $30 copay per visit 40% coinsurance after Coverage is limited to 30 visits per benefit period. medical deductible medical deductible is does not apply met Acupuncture $30 copay per visit 40% coinsurance after Coverage is limited to 20 visits per benefit period. medical deductible medical deductible is does not apply met Other Services in an Office Allergy Testing 20% coinsurance after 40% coinsurance after medical deductible is medical deductible is met met Prescription Drugs Dispensed in the office 30% coinsurance after 40% coinsurance after Maximum of $250 member cost share per drug. medical deductible is medical deductible is met met Surgery 20% coinsurance after 40% coinsurance after medical deductible is medical deductible is met met Preventive care / screenings / immunizations No charge 40% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 40% coinsurance after medical deductible is met Diagnostic Services Lab Office 20% coinsurance after 40% coinsurance after medical deductible is medical deductible is met met Freestanding Lab 20% coinsurance after 40% coinsurance after medical deductible is medical deductible is met met Outpatient Hospital 20% coinsurance after 40% coinsurance after medical deductible is medical deductible is met met Page 2 of 10