27 Benefits In - Network Out - of - Network • Urgent Care Visit Charge 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Allergy Testing 10% Coinsurance after Deductible 40% 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 40% Coinsurance after Deductible • Diagnostic Labs (other than reference labs) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Diagnostic x - ray 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Other Diagnostic Tests (including hearing and EKG) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Office Surgery (including anesthesia) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Prescription Drugs Administered in the Office (other than allergy serum) 10% Coinsurance after Deductible 30% 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) $0 Copayment per visit after Deductible Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care - Only Providers (Mental Health and Substance Use Disorder Services) $0 Copayment per visit after Deductible Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care - Only Providers (Specialty Care Services) $0 Copayment per visit 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.