Health Insurance, continued Compare Health Insurance Plans, continued HEALTH SAVINGS PLAN NETWORK PLAN (HSA) Ambulance 20% after deductible is met $0 copay Virtual Care Services Virtual Care Of昀椀ce Visits $10 or $50 copay 20% after deductible is met See zip code table to determine if higher copay applies Virtual Care Urgent Care 20% after deductible is met $10 copay Mental Health and Substance Abuse Outpatient Of昀椀ce Visits 20% after deductible is met $10 copay Inpatient 20% after deductible is met 20% after deductible is met Outpatient Therapy Services PT/OT 20% after deductible is met $10 copay Cardiac Rehab/Dialysis 20% after deductible is met 20% after deductible is met Outpatient Imaging and Lab Diagnostic Testing 20% after deductible is met 20% after deductible is met (CT/PET Scan/MRI) Diagnostic X-Rays 20% after deductible is met 20% after deductible is met Labs: Preventive 100% coverage 100% coverage Labs: Diagnostic 20% after deductible is met 100% coverage Hospice 20% after deductible is met 20% after deductible is met Durable Medical Equipment 20% after deductible is met 20% after deductible is met (DME) | 9 |