• Diagnostic X-ray 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible • Other Diagnostic 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Tests: Hearing, Deductible Deductible Deductible EKG, EEG etc. • Advanced 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Diagnostic Imaging Deductible Deductible Deductible (including MRIs, CAT scans) • Therapy: - Chiropractic / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Osteopathic / Deductible Deductible Deductible Manipulative Therapy - Physical 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Therapy Deductible Deductible Deductible - Speech 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Therapy Deductible Deductible Deductible - Occupational 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Therapy Deductible Deductible Deductible - Radiation / 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Chemotherapy / Deductible Deductible Deductible Respiratory Therapy - Dialysis 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Deductible Deductible Deductible - Cardiac 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Rehabilitation Deductible Deductible Deductible - Pulmonary 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Therapy Deductible Deductible Deductible See “Therapy Services” for details on Benefit Maximums. • Prescription Drugs 20% Coinsurance after 40% Coinsurance after 50% Coinsurance after Administered in an Deductible Deductible Deductible Outpatient Facility (other than allergy serum) Physical Therapy See “Therapy Services.” Preventive Care No Copayment, No Copayment, 50% Coinsurance after Deductible, or Deductible, or Deductible Coinsurance Coinsurance 26