22 Benefits In - Network Out - of - Network • Primary Care Physician / Provider (PCP) - Includes Ob/Gyn In - Person Visits: $40 Copayment per visit Virtual Visits: $40 Copayment per visit 30% Coinsurance after Deductible • Additional Telehealth/Telemedicine Services from a Primary Care Provider (PCP) (as required by law) $40 Copayment per visit 30% Coinsurance after Deductible • Mental Health and Substance Use Disorder Provider (Including Psychotherapy and Habilitative / Rehabilitative Therapy Services) In - Person Visits: $45 Copayment per visit Virtual Visits: $45 Copayment per visit 30% Coinsurance after Deductible • Specialty Care Physician / Provider (SCP) In - Person Visits: $45 Copayment per visit Virtual Visits: $45 Copayment per visit 30% Coinsurance after Deductible • Additional Telehealth/Telemedicine Services from a Specialty Care Provider (SCP) (as required by law) $45 Copayment per visit 30% Coinsurance after Deductible • Retail Health Clinic Visit $40 Copayment per visit 30% Coinsurance after Deductible • Family Planning, Diabetes Education, and Nutritional Counseling (Medical) $45 Copayment per visit 30% Coinsurance after Deductible • Nutritional Counseling (Mental Health and Substance Use Disorder) $45 Copayment per visit 30% Coinsurance after Deductible • Allergy Testing 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Shots / Injections (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Allergy Shots / Injections (including allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible