21 Benefits In-Network Out-of-Network - Speech Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Occupational Therapy 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible 50% Coinsurance after Deductible - Radiation / Chemotherapy Respiratory Therapy 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 Out-of-Network Providers may also bill you for any charges over the Plan’s Maximum Allowed Amount. See “Therapy Services” for details on Benefit Maximums. • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 50% Coinsurance after Deductible Orthotics See “Durable Medical Equipment (DME), Medical Devices, and Supplies.” Outpatient Facility Services • Facility Surgery Charge 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Facility Surgery Lab 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Facility Surgery X-ray 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Doctor Surgery Charges 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Other Doctor Charges (including Anesthesiologist, Pathologist, Radiologist, Surgical Assistant) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Other Facility Charges (for procedure rooms) 20% Coinsurance after Deductible 50% Coinsurance after Deductible • Mental Health / Substance Use Disorder Outpatient Facility Services (Partial Hospitalization Program / Intensive Outpatient Program) 20% Coinsurance after Deductible 50% Coinsurance after Deductible