22 Benefits In-Network Out-of-Network • Mental Health / Substance Use Disorder Outpatient Facility Provider Services (e.g., Doctor and other professional Providers in a Partial Hospitalization Program / Intensive Outpatient Program) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Shots/Injections (other than allergy serum) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Allergy Shots/Injections (including allergy serum) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic Lab 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic X-ray 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Other Diagnostic Tests: Hearing EKG, EEG etc. 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Therapy: - Chiropractic / Osteopathic / Manipulative Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Physical Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Speech Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Occupational Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible 50% 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 50% Coinsurance after Deductible Physical Therapy See “Therapy Services.”