Richmond Community School Trust HealthSync Options POS 3 Tier Option 4 Rx Carved out -Custom Page 5 of 9 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 Manipulation Therapy Coverage is limited to 12 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Pulmonary rehabilitation Coverage is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office $30 copay per visit medical deductible does not apply $80 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Dialysis/Hemodialysis Office No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met