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 6 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  Office, health center, and home medical services 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  Hospital outpatient medical services $40 copayment per visit after deductible 20% after deductible Medical Care Outpatient Visits (continued)  Acupuncture services (12-visit benefit limit per member per calendar year) $40 copayment per visit after deductible 20% after deductible Medical Formulas Certain medical formulas and low protein foods See Prescription Drugs and Supplies See Prescription Drugs and Supplies  Inpatient admissions in a General Hospital Hospital services No charge after deductible 20% after deductible Physician and other covered professional provider services No charge after deductible 20% after deductible  Inpatient admissions in a Mental Hospital or Substance Use Facility Facility services No charge after deductible 20% after deductible Physician and other covered professional provider services No charge after deductible 20% after deductible Mental Health and Substance Use Treatment  Outpatient services $25 copayment per visit after deductible 20% after deductible  Oxygen and equipment for its administration No charge after deductible 20% after deductible Oxygen and Respiratory Therapy  Outpatient respiratory therapy See Medical Care Outpatient Visits See Medical Care Outpatient Visits  Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests  Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient Podiatry Care  Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits