Common use of Mental Health or Substance Use Clause in Contracts

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 25 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 50 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 25 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 50 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 7080% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 40 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 50 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 75 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 125 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 175 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 50 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 75 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 7075% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 125 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 175 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 70100% of eligible charges after the deductible. 50% of eligible charges after the deductible.

Mental Health or Substance Use. Disorder 100% of eligible charges after a $45 member copayment per visit for visits for a mental health or substance use disorder. Deductible does not apply. Specialist 100% of eligible charges after a $60 member copayment per visit for visits with a specialist, except for visits for a mental health or substance use disorder. Deductible does not apply. 50% of eligible charges after the deductible. • Diagnostic imaging, including magnetic resonance imaging and computing tomography, laboratory tests and pathology. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Surgical Services 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Web based (online) care. • Convenience Care Center. 100% of eligible charges. Deductible does not apply. Not covered. • Urgent Care Center 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Allergy injections with no office visit. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 70% of eligible charges after the deductible. 50% of eligible charges after the deductible.