14 these cases you should determine where you will receive the service (i.e., in a doctor’s office, at an outpatient hospital facility, etc.) and look up that location to find out which cost share will apply. For example, you might get physical therapy in a doctor’s office, an outpatient hospital facility, or during an inpatient hospital stay. For services in the office, look up “Office and Home Visits.” For services in the outpatient department of a hospital, look up “Outpatient Facility Services.” For services during an inpatient stay, look up “Inpatient Services.” Benefits In-Network Out-of-Network Acupuncture 20% Coinsurance after Deductible 50% Coinsurance after Deductible Allergy Services Benefits are based on the setting in which Covered Services are received. Ambulance Services (Ground, Air, and Water) Emergency Services 20% Coinsurance after Deductible For ground or water ambulance services, Out-of-Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out-of-Network Providers cannot bill you for more than your applicable In-Network Deductible, Coinsurance, and/or Copayment. Ambulance Services (Ground, Air, and Water) Non- Emergency Services 20% Coinsurance after Deductible For ground or water ambulance services, Out-of-Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out-of-Network Providers cannot bill you for more than your applicable In-Network Deductible, Coinsurance, and/or Copayment. Important Note: All scheduled ambulance services for non-Emergency transfers, except transfers from one acute Facility to another, must be approved through precertification. Please see “Getting Approval for Benefits” for details. Autism Spectrum Disorders Benefits are based on the setting in which Covered Services are received. Behavioral Health Services Mental Health and Substance Use Disorder Services are covered as required by state and federal law. Please see the rest of this Schedule for the cost shares that apply in each setting. Cardiac Rehabilitation See “Therapy Services.”