• Durable Medical 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Equipment (DME) Deductible Deductible Deductible and Medical Devices • Orthotics 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Prosthetics 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Medical and Surgical 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Supplies Deductible Deductible Deductible The cost-shares listed above apply when your Provider submits separate bills for the equipment or supplies. Prosthetic limbs (artificial leg or arm) or an Orthotic custom fabricated brace or support designed as a component for a Prosthetic limb are covered the same as any other Medically Necessary items and services and will be subject to the same annual Deductible, Coinsurance, and Copayment as any other service under this Plan. • Wigs Needed After One wig per Benefit Period. In- and Out-of-Network combined Cancer Treatment Benefit Maximum The Plan’s reimbursement for durable medical equipment, orthotics, prosthetics, devices and supplies, and wigs will be based on the Maximum Allowed Amount for a standard item that is Medically Necessary to meet your needs. If you choose to purchase an item with features that exceed what is Medically Necessary, benefits will be limited to the Maximum Allowed Amount for the standard item, and you will be required to pay any costs that exceed the Maximum Allowed Amount. Please check with your Provider or contact us if you have questions about the Maximum Allowed Amount. Emergency Room Services Emergency Room • Emergency Room $250 Copayment per visit then 20% Coinsurance after Deductible Facility Charge Copayment waived if admitted • Emergency Room 20% Coinsurance after Deductible Doctor Charge (ER physician, radiologist, anesthesiologist, surgeon) • Emergency Room 20% Coinsurance after Deductible Doctor Charge (Mental Health / Substance Use Disorder) • Other Facility 20% Coinsurance after Deductible Charges (including diagnostic x-ray and lab services, medical supplies) 18