15 The tables below outline the Plan’s Covered Services and the cost share(s) you must pay. In many spots you will see the statement, “Benefits are based on the setting in which Covered Services are received.” In these cases you should determine where you will receive the service (i.e., in a doctor’s office, at an outpatient hospital facility, etc.) and look up that location to find out which cost share will apply. For example, you might get physical therapy in a Doctor’s office, an Outpatient Hospital Facility, or during an Inpatient Hospital stay. For services in the office, look up “Office and Home Visits.” For services in the Outpatient department of a Hospital, look up “Outpatient Facility Services.” For services during an Inpatient stay, look up “Inpatient Services.” Benefits Allergy Services Benefits are based on the setting in which Covered Services are received. Ambulance Services (Ground, Air, and Water) Emergency Services 20% Coinsurance after Deductible Ambulance Services (Ground, Air, and Water) Non-Emergency Services 20% Coinsurance after Deductible Important Note: All scheduled ground ambulance services for non-Emergency transfers, except transfers from one acute Facility to another, must be approved through precertification. Please see “Getting Approval for Benefits” for details. Autism Spectrum Disorders Benefits are based on the setting in which Covered Services are received. Behavioral Health Services Mental Health and Substance Use Disorder Services are covered as required by state and federal law. Please see the rest of this Schedule for the cost shares that apply in each setting. Cardiac Rehabilitation See “Therapy Services.” Cellular and Gene Therapy Services Precertification required See the “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services” section later in this Schedule. Chemotherapy See “Therapy Services.” Chronic Pain Management Services Benefits are based on the setting in which Covered Services are received.