25 Respiratory Therapy - Dialysis 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Cognitive Rehabilitation Therapy + 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible See “Therapy Services” for details on Benefit Maximums. + If physical , occupational , speech , or cognitive rehabilitation therapy is provided for a Mental Health or Substance Use Disorder condition (based on the primary diagnosis on the claim form) , benefits will be paid under the Mental Health and Substance Use Disorder benefits, as required by law . • Prescription Drugs Administered in an Outpatient Facility (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Physical Therapy See “Therapy Services.” Preventive Care No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible Preventive Care for Chronic Conditions (per IRS guidelines) • Medical items, equipment and screenings No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible Please see the “What’s Covered” section for additional detail on IRS guidelines . Prosthetics See “ Durable Medical Equipment (DME ), Medical Devices, and Supplies. ” Pulmonary Therapy See “Therapy Services.” Radiation Therapy See “Therapy Services.”