PHP Schedule of Benefits for Legacy 1500 POS 9 Medical Benefits In-Network You Pay Doctor’s Office Visit Illness, Injury or Sickness. Emergency services in a Doctor’s office. Prior Authorization required for specific surgeries and specific drugs. Additional Copays, Deductible or Coinsurance may apply when you receive other services during a Doctor’s office visit. Office Visit Charge for Par Doctor of primary care practice areas of family practice, pediatrics, internal medicine, obstetrics and gynecology. Office Visit Charge for Par Doctor of specialty care. Other Services 20% after Deductible. The Out-of- Pocket Limit applies.Goto 20% after Deductible. The Out-of- Pocket Limit applies. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Other Practitioner Visits Chiropractor services are limited to 45 visits combined In- Network and Out-of-Network per Calendar Year across outpatient and other professional visits. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. LabCorp Routine Labs Routine lab services, such as but not limited to: pregnancy test; blood test; or urine test performed at a freestanding LabCorp facility. Urine drug screenings are limited to a total of 24 screenings per Calendar Year. No Charge Deductible waived 50% after Deductible. The Out-of- Pocket Limit applies. Diagnostic Routine radiology services, such as but not limited to: chest x-ray or MRI. Routine lab services, such as but not limited to: pregnancy test; blood test; or urine test performed at a facility other than LabCorp or in a Hospital (inpatient or outpatient) setting. Urine drug screenings are limited to a total of 24 screenings per Calendar Year. Prior Authorization required for specific radiology services. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Preventive Care Services rated 'A' or 'B' by the U.S. Preventive Services Task Force. Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for women and children as recommended by the Health Resources and Services Administration. Visit www.phpni.com or call PHP Customer Service for a list of No Charge Deductible waived 50% after Deductible. The Out-of- Pocket Limit applies. preventive services. Outpatient Prior Authorization required for specific surgeries and specific drugs. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. Inpatient Prior Authorization required. 20% after Deductible. The Out-of- Pocket Limit applies. 50% after Deductible. The Out-of- Pocket Limit applies. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024 Out-of-Network* You Pay