Page 2 of 9 Covered Medical Benefits Cost if you use an In-Network Provider Manipulation Therapy Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply Acupuncture Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply Other Services in an Office Allergy Testing $30 copay per visit medical deductible does not apply Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 30% coinsurance medical deductible does not 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 30% coinsurance after medical deductible is met Diagnostic Services X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital 30% coinsurance after medical deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $125 copay per day medical deductible does not apply Freestanding Radiology Center $125 copay per day medical deductible does not apply Outpatient Hospital $125 copay per day medical deductible does not apply Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. In-Network and Out-of-Network Providers: $30 copay per visit medical deductible does not apply Emergency Room Facility Services Your copay will be waived if admitted. In-Network and Out-of-Network Providers: $250 copay per visit and 30% coinsurance after medical deductible is met