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 $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable Specialist visit $60 / visit; $60 / chiropractor visit; $60 / acupuncture visit 20% coinsurance; 20% coinsurance / chiropractor visit; 20% coinsurance / acupuncture visit Deductible applies first; limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Preventive care/screening/immunization No charge 20% coinsurance Limited to age-based schedule and / or frequency; cost share waived for at least one mental health wellness 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 20% coinsurance Deductible applies first; pre- authorization may be required Imaging (CT/PET scans, MRIs) $1,000 20% coinsurance Deductible applies first; copayment applies per category of test / day; pre- authorization may be required