24 Benefits In-Network Out-of-Network • Acupuncture 20 visits per Benefit Period The limits for physical, occupational, and speech therapy will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice benefit. Note: If pulmonary rehabilitation is given as part of physical therapy, the Physical Therapy limit will apply instead of the Pulmonary Rehabilitation limit. Note: When you get physical, occupational, speech therapy, or cardiac rehabilitation, or pulmonary rehabilitation in the home, the Home Health Care Visit limit will apply instead of the Therapy Services limits listed above. Transplant Services See “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services.” Urgent Care Services (Office & Home* Visits) *Home visits are not the same as Home Health Care. For Home Health Care benefits please see the "Home Health Care" section. • Urgent Care Visit Charge 20% Coinsurance after Deductible 40% 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 • Diagnostic Labs (other than reference labs) 0% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic x-ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Other Diagnostic Tests (including hearing and EKG) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Office Surgery (including anesthesia) 20% Coinsurance after Deductible 40% Coinsurance after Deductible • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 40% 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.