25 Benefits In-Network Out-of-Network • Allergy Shots / Injections (including allergy serum) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic Labs (other than reference labs) No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Diagnostic x-ray No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Other Diagnostic Tests (including hearing and EKG) No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Office Surgery (including anesthesia) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 50% 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 Care-Only Providers through our mobile app and website: Out-of-Network Virtual Care-Only Providers: • Virtual Visits including Primary Care from Virtual Care-Only Providers (Medical Services) No Copayment, Deductible, or Coinsurance Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care-Only Providers (Mental Health and Substance Use Disorder Services) No Copayment, Deductible, or Coinsurance Please refer to the “Office and Home Visits” section. • Virtual Visits from Virtual Care-Only Providers (Specialty Care Services) No Copayment, Deductible, or Coinsurance 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.