injection(s) will be applied when the injection(s) is billed by itself. The PCP or SCP office visit Copayment/Coinsur ance will apply if an office visit is billed with an allergy injection. • Diagnostic Lab (i.e., No Copayment, No Copayment, 50% Coinsurance after other than Deductible, or Deductible, or Deductible reference labs) Coinsurance Coinsurance • Diagnostic x-ray No Copayment, No Copayment, 50% Coinsurance after Deductible, or Deductible, or Deductible Coinsurance Coinsurance • Other Diagnostic No Copayment, No Copayment, 50% Coinsurance after Tests (including Deductible, or Deductible, or Deductible hearing and EKG) Coinsurance Coinsurance • Advanced 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Diagnostic Imaging Deductible Deductible Deductible (including MRIs, CAT scans) • Office Surgery $75 Copayment per visit 40% Coinsurance after 50% Coinsurance after (including Deductible Deductible anesthesia) • Prescription Drugs 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Administered in the Deductible Deductible Deductible Office (other than allergy serum) Note: If you get urgent care at a Hospital or other outpatient Facility, please refer to “Outpatient Facility Services” for details on what you will pay. Virtual Visits (from Virtual Care-Only Providers through our mobile app Out-of-Network Virtual Virtual Care Only and website: Care-Only Providers: Providers) • Virtual Visits $0 Copayment per visit Please refer to the including Primary “Office and Home Care from Virtual Visits” section. Care-Only Providers (Medical Services) • Virtual Visits from $0 Copayment per visit Please refer to the Virtual Care-Only “Office and Home Providers (Mental Visits” section. Health and 29