Covered Medical Benefits Cost if you use an In-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; $25 copay per visit medical deductible does not usually found in major pharmacies or retail stores. apply Manipulation Therapy $25 copay per visit medical deductible does not Coverage is limited to 30 visits per benefit period. apply Acupuncture $25 copay per visit medical deductible does not Coverage is limited to 20 visits per benefit period. apply Other Services in an Office Allergy Testing 20% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office 30% coinsurance after medical deductible is met Maximum of $250 member cost share per drug. Surgery 20% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office 20% coinsurance after medical deductible is met Freestanding Lab 20% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met X-Ray Office 20% coinsurance after medical deductible is met Freestanding Radiology Center 20% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after medical deductible is met Freestanding Radiology Center 20% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met Page 2 of 9