Preventive Care for Chronic Conditions (per IRS guidelines) • Prescription Please refer to the “Prescription Drug Retail Pharmacy and Home Delivery Drugs (Mail Order) Benefits” section. • Medical items, No Copayment, No Copayment, 50% Coinsurance after equipment and Deductible, or Deductible, or Deductible screenings Coinsurance Coinsurance Please see the “What’s Covered” section for additional detail on IRS guidelines. Prosthetics See “Durable Medical Equipment (DME), Medical Devices, and Supplies.” Pulmonary Therapy See “Therapy Services.” Radiation Therapy See “Therapy Services.” Rehabilitation Benefits are based on the setting in which Covered Services are received. Services See “Inpatient Services” and “Therapy Services” for details on Benefit Maximums. Respiratory Therapy See “Therapy Services.” Skilled Nursing See “Inpatient Services.” Facility Speech Therapy See “Therapy Services.” Surgery Benefits are based on the setting in which Covered Services are received. Temporomandibular Benefits are based on the setting in which Covered Services are received. and Craniomandibular Joint Treatment Therapy Services Benefits are based on the setting in which Covered Services are received. Benefit Maximum(s): Benefit Maximum(s) are for In- and Out-of-Network visits combined, and for office and outpatient visits combined. 27