Common use of Observation Services Clause in Contracts

Observation Services. In a hospital or other health care facility 0% - After deductible Not Covered Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $20 Not Covered Retail clinics $20 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility 0% - After deductible Not Covered Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 50 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $20 30 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 50 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 30 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 45 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $35 Not Covered Enhanced $20 Not Covered Retail clinics $20 35 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible $45 Not Covered

Observation Services. In a hospital or other health care facility 0% - After deductible Not Covered Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 40 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $20 25 Not Covered Retail clinics $20 25 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 25 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 40 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $20 30 Not Covered Enhanced $15 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 15 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible $40 Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 45 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $35 Not Covered Enhanced $20 Not Covered Retail clinics $20 35 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible $45 Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. $0 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $30 40 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $20 30 Not Covered Enhanced $15 Not Covered Retail clinics $20 30 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 15 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible $40 Not Covered