Richmond Community School Trust HealthSync Opti POS HSA 3 Tier Opt E3 Rx Carved out -Custom Page 2 of 7 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Other Services in an Office Allergy Testing 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Prescription Drugs Dispensed in the office 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Surgery 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Preventive care / screenings / immunizations No charge No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Lab/Reference Lab 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Diagnostic Services X-Ray Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Radiology Center 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Emergency and Urgent Care Urgent Care 20% coinsurance after deductible is met 40% coinsurance after deductible is met 50% coinsurance after deductible is met Emergency Room Facility Services Your copay will be waived if admitted. $250 copay per visit and 20% coinsurance after deductible is met Same as In-Network Tier 1 Covered as In-Network Emergency Room Doctor and Other Services 20% coinsurance after deductible is met Same as In-Network Tier 1 Covered as In-Network