17 • Emergency Room Doctor Charge (ER physician, radiologist, anesthesiologist, surgeon) 20% Coinsurance after Deductible • Emergency Room Doctor Charge (Mental Health / Substance Use Disorder ) 20% Coinsurance after Deductible • Other Facility Charges (including diagnostic x - ray and lab services, medical supplies) 20% Coinsurance after Deductible • Advanced Diagnostic Imaging (including MRIs, CAT scans) 20% Coinsurance after Deductible As described in the “Consolidated Appropriations Act of 2021 Notice” at the front of this Booklet, for Emergency Services, Out - of - Network Providers may only bill you for any applicable Copayments, Deductible and Coinsurance and may not bill you for any charges over the Plan’s Maximum Allowed Amount until the treating Out - of - Network Provider has determined you are stable and followed the notice and consent process . Please refer to the Notice at the beginning of this Booklet for more details. Habilitative Services Benefits are based on the setting in which Covered Services are received. See “Therapy Services” for details on Benefit Maximums. Home Health Care • Home Health Care Visits from a Home Health Care Agency (Including intermittent skilled nursing services) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Home Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Home Infusion Therapy / Chemotherapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Specialty Prescription Drugs for Infusion / Injection – Other than Chemotherapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible