22 Benefits In - Network Out - of - Network • Specialty Care Physician / Provider (SCP) In - Person Visits: 10% Coinsurance after Deductible Virtual Visits: 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Additional Telehealth/Telemedicine Services from a Specialty Care Provider (SCP) (as required by law) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Retail Health Clinic Visit 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Family Planning, Diabetes Education, and Nutritional Counseling (Medical) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Nutritional Counseling (Mental Health and Substance Use Disorder) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Allergy Testing 10% Coinsurance after Deductible 4 0% 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 4 0% Coinsurance after Deductible • Diagnostic Lab (other than reference labs) 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Diagnostic X - ray 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests (including Hearing and EKG) 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Vision Exam (non - routine) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 10% Coinsurance after Deductible 40% Coinsurance after Deductible • Office Surgery (including anesthesia) 10% Coinsurance after Deductible 30% Coinsurance after Deductible • Therapy Services: