27 Benefits In - Network Out - of - Network • Occupational Therapy Unlimited • Speech Therapy Unlimited • Manipulation Therapy 12 visits per Benefit Period • Cardiac Rehabilitation Unlimited • Pulmonary Rehabilitation Unlimited The limits for physical, occupational, and speech therapy will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit (based on the primary diagnosis on the claim form). Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice benefit. Note: When you get physical, occupational, speech therapy, or cardiac rehabilitation, or pulmonary rehabilitation in the home, the Home Health Care Visit limit will apply instead of the Therapy Services limits listed above. Transplant Services See “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services”. Urgent Care Services (Office & Home* Visits) *Home visits are not the same as Home Health Care. For Home Health Care benefits please see the "Home Health Care" section. • Urgent Care Visit Charge $40 Copayment per visit 30% Coinsurance after Deductible • Allergy Testing 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Shots / Injections (other than allergy serum) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Allergy Shots / Injections (including allergy serum) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Diagnostic Labs (other than reference labs) No Copayment, Deductible, or Coinsurance 30% Coinsurance after Deductible • Diagnostic x - ray No Copayment, Deductible, or Coinsurance 30% Coinsurance after Deductible • Other Diagnostic Tests (including hearing and EKG) No Copayment, Deductible, or Coinsurance 30% Coinsurance after Deductible