25 - Dialysis No Copayment, Deductible, or Coinsurance No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy See PCP / SCP Copayment See PCP / SCP Copayment 50% Coinsurance after Deductible - Cardiac Rehabilitation $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Pulmonary Therapy $30 Copayment per visit $80 Copayment per visit 50% Coinsurance after Deductible - Cognitive Rehabilitation Therapy+ $30 Copayment per visit $80 Copayment per visit 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. Out-of-Network Providers may also bill you for any charges over the Plan’s Maximum Allowed Amount. • Prescription Drugs Administered in the Office (other than allergy serum) 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible Orthotics See “Durable Medical Equipment (DME), Medical Devices, and Supplies.” Outpatient Facility Services • Facility Surgery Charge 20% Coinsurance after Deductible $250 Copayment per visit then 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Facility Surgery Lab 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Facility Surgery X-ray 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Ancillary Services 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Doctor Surgery Charges 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible • Other Doctor Charges (including Anesthesiologist, Pathologist, 20% Coinsurance after Deductible 40% Coinsurance after Deductible 50% Coinsurance after Deductible