20 Benefits In-Network Out-of-Network • Specialty Care Physician / Provider (SCP) (including In- Person and/or Virtual Visits) In-Person Visits: 20% Coinsurance after Deductible Virtual Visits: 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Additional Telehealth/Telemedicine Services from a Specialty Care Provider (SCP) (as required by law) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Retail Health Clinic Visit 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Counseling- includes Family Planning and Nutritional Counseling (Other than Eating Disorders) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Nutritional Counseling for Eating Disorders 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Allergy Testing 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 (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 • Therapy Services: - Chiropractic / Osteopathic / Manipulative Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Physical Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible