27 - Physical Therapy+ 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Speech Therapy+ 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Occupational Therapy+ 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible - 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.