Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $50 / visit Not covered Deductible applies first; a telehealth cost share may be applicable Specialist visit $75 / visit; $75 / chiropractor visit; $75 / acupuncture visit Not covered Deductible applies first; limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Preventive care/screening/immunization No charge Not covered GYN exam limited to one exam per calendar year; a telehealth 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. If you have a test Diagnostic test (x-ray, blood work) No charge Not covered Deductible applies first; pre- authorization required for certain services Imaging (CT/PET scans, MRIs) $1,000 Not covered Deductible applies first; copayment applies per category of test / day; pre- authorization required for certain services