Covered Medical Benefits Cost if you use an In-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; $30 copay per visit medical deductible does not usually found in major pharmacies or retail stores. apply Manipulation Therapy $30 copay per visit medical deductible does not Coverage is limited to 20 visits per benefit period. apply Acupuncture $30 copay per visit medical deductible does not Coverage is limited to 20 visits per benefit period. apply Other Services in an Office Allergy Testing $30 copay per visit medical deductible does not apply Prescription Drugs Dispensed in the office 30% coinsurance medical deductible does not Maximum of $250 member cost share per drug. apply Surgery $30 copay per surgery medical deductible does not apply 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 25% coinsurance after medical deductible is met X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital 25% coinsurance after medical deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $100 copay per service medical deductible does not apply Freestanding Radiology Center $100 copay per service medical deductible does not apply Outpatient Hospital $100 copay per service medical deductible does not apply Page 2 of 10