29 The limits for physical, occupational, and speech therapy will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit (based on the primary diagnosis on the claim form). Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice benefit. Note: If pulmonary rehabilitation is given as part of physical therapy, the Physical Therapy limit will apply instead of the pulmonary rehabilitation limit. Note: When you get physical, occupational, speech therapy, cardiac rehabilitation or, pulmonary rehabilitation in the home, the Home Health Care Visit limit will apply instead of the Therapy Services limits listed above. Transplant Services See “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services, Cellular and Gene Therapy Services.” Urgent Care Services (Office & Home* Visits) *Home visits are not the same as Home Health Care. For Home Health Care benefits please see the "Home Health Care" section. • Urgent Care Visit Charge $75 Copayment per visit 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Allergy Testing 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Shots / Injections (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Allergy Shots / Injections (including allergy serum) A $10 Copayment for allergy injection(s) will be applied when the injection(s) is billed by itself. The PCP or SCP office visit Copayment/Coinsuran ce will apply if an office visit is billed with an allergy injection. 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Diagnostic Lab (i.e., other than reference labs) No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible • Diagnostic x-ray No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible