• Physical and 40 visits per Benefit Period Occupational Therapy • Speech Therapy 20 visits per Benefit Period • Manipulation 12 visits per Benefit Period Therapy • Cardiac 36 visits per Benefit Period Rehabilitation • Pulmonary 20 visits per Benefit Period Rehabilitation 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. 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.” 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 $75 Copayment per visit 40% Coinsurance after 50% Coinsurance after Charge Deductible Deductible • Allergy Testing 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Shots / Injections 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after (other than allergy Deductible Deductible Deductible serum) • Allergy Shots / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Injections (including Deductible Deductible Deductible allergy serum) A $10 Copayment for allergy 28