16 Diagnostic Services • Reference Labs No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • All Other Diagnostic Services Benefits are based on the setting in which Covered Services are received Dialysis See “Therapy Services.” Durable Medical Equipment (DME), Medical Devices, and Supplies • Durable Medical Equipment (DME) and Medical Devices 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Orthotics 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Prosthetics 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Medical and Surgical Supplies 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible The cost shares listed above apply when your Provider submits separate bills for the equipment or supplies. Prosthetic limbs (artificial leg or arm) or an Orthotic custom fabricated brace or support designed as a component for a Prosthetic limb are covered the same as any other Medically Necessary items and services and will be subject to the same annual Deductible, Coinsurance, and Copayment as any other service under this Plan. • Wigs Needed After Cancer Treatment Benefit Maximum O ne wig per Benefit Period . In - and Out - of - Network combined The Plan’s reimbursement for durable medical equipment, orthotics, prosthetics, devices and supplies, and wigs will be based on the Maximum Allowed Amount for a standard item that is Medically Necessary to meet your needs. If you choose to purchase an item with features that exceed what is Medically Necessary, benefits will be limited to the Maximum Allowed Amount for the standard item, and you will be required to pay any costs that exceed the Maximum Allowed Amount. Please check with your Provider or con tact us if you have questions about the Maximum Allowed Amount. Emergency Room Services Emergency Room • Emergency Room Facility Charge $250 Copayment per visit then 20% Coinsurance after Deductible Copayment waived if admitted