Page 2 of 7 * For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance None Specialist visit 20% coinsurance 40% coinsurance None Preventive care/ screening/ immunization No Charge 40% coinsurance You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x- ray, blood work) 20% coinsurance 40% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount. Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.