All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Primary care visit to treat an injury or illness $50 / visit Not covered Deductible applies first; a telehealth cost share may be applicable $75 / visit; $75 / Deductible applies first; limited to 12 Specialist visit chiropractor visit; $75 Not covered acupuncture visits per calendar year; / acupuncture visit a telehealth cost share may be If you visit a health care applicable provider’s office or clinic GYN exam limited to one exam per calendar year; a telehealth cost share may be applicable. You may have to Preventive care/screening/immunization No charge Not covered pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Deductible applies first; pre- Diagnostic test (x-ray, blood work) No charge Not covered authorization required for certain services If you have a test Deductible applies first; copayment Imaging (CT/PET scans, MRIs) $1,000 Not covered applies per category of test / day; pre- authorization required for certain services $15 / retail supply or Deductible applies first; up to 30-day Generic drugs $30 / mail service Not covered retail (90-day mail service) supply; If you need drugs to treat supply cost share may be waived or reduced your illness or condition Preferred brand drugs 50% coinsurance Not covered for certain covered drugs and More information about supplies; pre-authorization required prescription drug coverage Non-preferred brand drugs 50% coinsurance Not covered for certain drugs is available at Deductible applies first; when bluecrossma.org/medicatio Applicable cost share obtained from a designated specialty n Specialty drugs (generic, preferred, Not covered pharmacy; cost share may be waived non-preferred) or reduced for certain covered drugs and supplies; pre-authorization required for certain drugs Page 2 of 7