Page 2 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Delivery $750 copay per pregnancy after medical deductible is met 50% coinsurance after medical deductible is met Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Manipulation Therapy Coverage is limited to 30 visits per benefit period. $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Acupuncture Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Services in an Office Allergy Testing $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. $250 copay per day medical deductible does not apply 50% coinsurance after medical deductible is met Surgery $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Freestanding Lab No charge 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services X-Ray Office $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met