Huntington County Community School Corp HS 3 Tier Opt 5 Rx Carveout Page 2 of 9 Covered Medical Benefits Cost if you use a Preferred Network Provider Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. $15 copay per visit medical deductible does not apply $40 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Services in an Office Allergy Testing When Allergy injections are billed separately by network providers, the member is responsible for a $10 copay. When billed as part of an office visit, there is no additional cost to the member for the injection. 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Surgery $30 copay per visit medical deductible does not apply‡ $80 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge No charge 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office No charge No charge 50% coinsurance after medical deductible is met Freestanding Lab/Reference Lab No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services X-Ray Office No charge No charge 50% coinsurance after medical deductible is met Outpatient Hospital 20% coinsurance after medical deductible is met 40% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met