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 $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable 20% coinsurance; Deductible applies first; limited to 12 $60 / visit; $60 / 20% coinsurance / acupuncture visits per calendar year; Specialist visit chiropractor visit; $60 chiropractor visit; a telehealth cost share may be / acupuncture visit 20% coinsurance / applicable acupuncture visit If you visit a health care Limited to age-based schedule and / provider’s office or clinic or frequency; cost share waived for at least one mental health wellness exam per calendar year; a telehealth Preventive care/screening/immunization No charge 20% coinsurance cost share may be applicable. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required If you have a test Deductible applies first; copayment Imaging (CT/PET scans, MRIs) $1,000 20% coinsurance applies per category of test / day; pre- authorization may be required Page 2 of 8