25 Benefits In - Network Out - of - Network • Therapy: - Chiropractic / Osteopathic / Manipulative Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Physical Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Speech Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Occupational Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible - Cognitive Rehabilitation Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible See “Therapy Services” for details on Benefit Maximums. + If physical, occupational, speech, or cognitive rehabilitation therapy is provided for a Mental Health or Substance Use Disorder condition (based on the primary diagnosis on the claim form), benefits will be paid under the Mental Health and Substance Use D isorder benefits, as required by law. • Prescription Drugs Administered in an Outpatient Facility (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible Physical Therapy See “Therapy Services.” Preventive Care No Copayment, Deductible, or Coinsurance 30% Coinsurance after Deductible Prosthetics See “ Durable Medical Equipment (DME), Medical Devices, and Supplies. ” Pulmonary Therapy See “Therapy Services.” Radiation Therapy See “Therapy Services.”