Schedule of Benefits (continued) Preferred Blue PPO Deductible II This chart shows your cost share for covered services. You must pay all charges in excess of a benefit limit. Page 4 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  Office, health center, and home services by a family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, or multi-specialty provider group; or by a physician assistant or nurse practitioner designated by the health plan as primary care $25 copayment per visit after deductible 20% after deductible Emergency Medical Outpatient Services (continued) by another specialist or other covered provider (non-hospital), including a physician assistant or nurse practitioner designated by the health plan as specialty care $40 copayment per visit after deductible 20% after deductible Home Health Care Home care program No charge after deductible 20% after deductible Hospice Services Inpatient or outpatient hospice services for terminally ill No charge after deductible 20% after deductible  Inpatient services See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care  Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient  Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests Infertility Services  Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits  Outpatient lab tests by a general hospital No charge after deductible 20% after deductible by other covered providers No charge after deductible 20% after deductible  Outpatient x-rays and other imaging tests (other than advanced imaging tests) by a general hospital No charge after deductible 20% after deductible Lab Tests, X-Rays, and Other Tests (diagnostic services) by other covered providers No charge after deductible 20% after deductible