All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Deductible applies first; family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, limited services clinic, multi-specialty provider group, or by a physician Primary care visit to treat an injury or illness $25 / visit 20% coinsurance assistant or nurse practitioner designated as primary care; in-network cost share waived for the first two diabetic PCP and / or specialist visits per calendar year; a telehealth cost share may be applicable Deductible applies first; includes physician assistant or nurse If you visit a health care 20% coinsurance; practitioner designated as specialty provider’s office or clinic $40 / visit; $40 / 20% coinsurance / care; in-network cost share waived for Specialist visit chiropractor visit; $40 chiropractor visit; the first two diabetic PCP and / or / acupuncture visit 20% coinsurance / specialist visits per calendar year; acupuncture visit limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Deductible applies first for out-of- network; limited to age-based schedule and / or frequency; cost share waived for at least one mental health wellness exam per calendar Preventive care/screening/immunization No charge 20% coinsurance year; a telehealth cost share may be applicable. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Page 2 of 8