22 Benefits In-Network Out-of-Network • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • 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 See “Therapy Services” for details on Benefit Maximums. • 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 40% Coinsurance after Deductible Preventive Care for Chronic Conditions (per IRS guidelines) • Medical items, equipment and screenings No Copayment, Deductible, or Coinsurance 40% Coinsurance after Deductible Please see the “What’s Covered” section for additional detail on IRS guidelines. Prosthetics See “Durable Medical Equipment (DME), Medical Devices, and Supplies.”