Common use of COVERED SERVICES AND BENEFITS Clause in Contracts

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.

COVERED SERVICES AND BENEFITS. All Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services (except in emergencies) must Services, benefit limitations and out- of- pocket maximums can be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers found in the applicable network Schedule of Participating Specialists Copayments and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMOBenefit Limits. A Copayment for Covered Services Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTENote: Your Group has made the following additional benefits available. Copayments shown below indicate for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount You are required to payhas been reached: S Pharmacy Benefits Requirements All Covered Services, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and out-of-pocket maximums Benefit Limits; • may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office have limitations, restrictions or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory exclusions described in Limitations and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 CopayExclusions; unless otherwise covered under Inpatient Hospital Services• may require Preauthorization.

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, Clinics and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization Preauthorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 7,350 $17,400 14,700 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 25 Copay $60 45 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Dialysis -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other -Other X-Ray Services Outpatient -Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Therapies, per visit Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.

COVERED SERVICES AND BENEFITS. All Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services (except in emergencies) must Services, benefit limitations and out- of- pocket maximums can be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers found in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMOSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Covered Services Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTENote: Copayments shown below indicate Your Group has made additional pharmacy benefits available. Copayment for pharmacy benefits do not apply to the amount You are required medical out- of- pocket maximum amount, but will apply to paythe out- of- pocket maximums for Pharmacy Benefits indicated on the PHARMACY BENEFITS; SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. Requirements All Covered Services, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums specifically described:  must be Medically Necessary;  must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO;  must be rendered by a Participating Provider;  are subject to the Copayment in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS;  may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office have limitations, restrictions or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copayexclusions described in LIMITATIONS AND EXCLUSIONS; unless otherwise covered under Inpatient Hospital Services may require Preauthorization.

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Female Members may visit a Participating OB/GYN Physician in their PCP's Provider network for diagnosis and treatment without a Referral from their PCP. Urgent Care, Care and Retail Health Clinics, and Virtual Visits Clinics do not require Primary Care Physician/Practitioner Physician Referral. Some services may require Prior Authorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket Out‐of‐pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and Amount. Copayments will be applied for each occurrence unless otherwise indicated. You will not be responsible for any Copayments and once the out-of-pocket maximum(s) listed below have been met. Copayments and out‐of‐pocket maximums may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Some services may require Preauthorization by HMO. Out‐of‐Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 4,000 $17,400 8,000 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 40 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 1,500 Copay Outpatient Facility Services Outpatient Surgery Radiation Therapy and Chemotherapy Dialysis $100 750 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray X‐Ray Services Arteriograms, Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Myelogram, Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray X‐Ray Services Other Outpatient Lab $200 250 Copay $100 No Copay $100 No Copay Rehabilitation Services Rehabilitation Services and Habilitation Therapies $40 Copay for PCP or $60 Copay for Specialist, $1,500 Copay for Inpatient Hospital Services Rehabilitation or $60 Copay for Outpatient Facility Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Servicesas applicable.

COVERED SERVICES AND BENEFITS. All Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services (except in emergencies) must Services, benefit limitations and out- of- pocket maximums can be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers found in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMOSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Covered Services Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTENote: Copayments shown below indicate Your Group has made the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicatedfollowing additional benefits available. Copayments and out-of-for these services do not apply to the out- of- pocket maximums may be adjusted for various reasons as permitted by applicable lawmaximum amount. Out-of-Pocket Maximums Per Calendar Year including You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: • Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.Sample

COVERED SERVICES AND BENEFITS. All Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services (except in emergencies) must Services, benefit limitations and out- of- pocket maximums can be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers found in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMOSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Covered Services Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTENote: Your Group has made the following additional benefits available. Copayments shown below indicate for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount You are required to payhas been reached: S Pharmacy Benefits Requirements All Covered Services, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums specifically described:  must be Medically Necessary;  must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO;  must be rendered by a Participating Provider;  are subject to the Copayment in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS;  may be adjusted for various reasons as permitted by applicable law. Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office have limitations, restrictions or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copayexclusions described in LIMITATIONS AND EXCLUSIONS; unless otherwise covered under Inpatient Hospital Services may require Preauthorization.

COVERED SERVICES AND BENEFITS. All Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services (except in emergencies) must Services, benefit limitations and out- of- pocket maximums can be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers found in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMOSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Covered Services Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTENote: Copayments shown below indicate Your Group has made the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicatedfollowing additional benefits available. Copayments and out-of-for these services do not apply to the out- of- pocket maximums may be adjusted for various reasons as permitted by applicable lawmaximum amount. Out-of-Pocket Maximums Per Calendar Year including You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Benefits Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.Sample