26 Benefits In - Network Out - of - Network • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Office Surgery (including anesthesia) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible Note: If you get urgent care at a Hospital or other outpatient Facility, please refer to “Outpatient Facility Services” for details on what you will pay. Virtual Visits ( from Virtual Care - Only Providers ) Virtual Visits Conducted through our mobile app and website: Other Virtual Visits: • Virtual Visits including Primary Care from Virtual Care - Only Providers (Medical Services) No Copayment, Deductible, or Coinsurance Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care - Only Providers (Mental Health and Substance Use Disorder Services) No Copayment, Deductible, or Coinsurance Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care - Only Providers (Specialty Care Services) 20% Coinsurance after Deductible Please refer to the “Office and Home Visits” section. If Preventive Care is provided during a Virtual Visit, it will be covered under the “Preventive Care” benefit, as required by law. Please refer to that section for details. Vision Services (For medical and surgical treatment of injuries and/or diseases of the eye) Certain vision screenings required by Federal law are covered under the "Preventive Care" benefit. Benefits are based on the setting in which Covered Services are received. Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services Please call our Transplant Department as soon as you think you may need a Covered Procedure to talk about your benefit options. To get the In - Network Level of benefits under your Plan, you must get certain Covered Procedures from an Approved In - Network Provider. Even if a Hospital is an In - Network Provider for other services, it may not be an Approved In - Network Provider for certain Covered Procedures. Please see the “What’s Covered” section for further details. The requirements described below do not apply to the following: