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 If you need drugs to treat Generic drugs $30 / mail service Not covered retail (90-day mail service) supply; your illness or condition supply cost share may be waived for certain More information about Preferred brand drugs 50% coinsurance Not covered covered drugs and supplies; pre- prescription drug coverage authorization required for certain is available at Non-preferred brand drugs 50% coinsurance Not covered drugs bluecrossma.org/medicatio Applicable cost share Deductible applies first; when n Specialty drugs (generic, preferred, Not covered obtained from a designated specialty non-preferred) pharmacy; pre-authorization required for certain drugs Page 2 of 7