Page 2 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. 10% coinsurance after deductible is met 30% coinsurance after deductible is met Manipulation Therapy Coverage is limited to 30 visits per benefit period. 10% coinsurance after deductible is met 30% coinsurance after deductible is met Acupuncture Coverage is limited to 20 visits per benefit period. 10% coinsurance after deductible is met 30% coinsurance after deductible is met Other Services in an Office Allergy Testing 10% coinsurance after deductible is met 30% coinsurance after deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 30% coinsurance after deductible is met 30% coinsurance after deductible is met Surgery 10% coinsurance after deductible is met 30% coinsurance after deductible is met Preventive care / screenings / immunizations No charge 30% coinsurance after 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 10% coinsurance after deductible is met 30% coinsurance after deductible is met Freestanding Lab 10% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Hospital 10% coinsurance after deductible is met 30% coinsurance after deductible is met Diagnostic Services X-Ray Office 10% coinsurance after deductible is met 30% coinsurance after deductible is met Freestanding Radiology Center 10% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Hospital 10% coinsurance after deductible is met 30% coinsurance after deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 10% coinsurance after deductible is met 30% coinsurance after deductible is met Freestanding Radiology Center 10% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Hospital 10% coinsurance after deductible is met 30% coinsurance after deductible is met