Common use of Office Visits (other than Preventive Care Services) Clause in Contracts

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits PCP practices with PCMH model of care 0% - After deductible 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visitscalls. PCP practices with PCMH model of care 0% - After deductible 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits visit 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visitscalls. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% $20 - After deductible 40% - After deductible Pediatric clinic visits 0% $15 - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% $15 - After deductible 40% - After deductible Retail clinics 0% $15 - After deductible 40% - After deductible 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 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. 0% $20 - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% $15 - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible $50 40% - After deductible Pediatric clinic visits 0% - After deductible visit PCP practices with PCMH model of care $20 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible does not practice with PCMH model of care $40 40% - After deductible 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 40% - After deductible PCP does not practice with PCMH model of care $40 40% - After deductible Retail clinics $40 40% - After deductible 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. 0% - After deductible $50 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0$40 40% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 40% - After deductible Organ transplant services 020% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible

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% 20% - After deductible 40Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 20% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40$40 20% - After deductible 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 Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible 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. 0% - After deductible 40$40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40$30 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible

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$0 20% - After deductible 40Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 20% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40$30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40$20 20% - After deductible Retail clinics 0$20 20% - After deductible 40% - After deductible 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 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. 0% - After deductible 40$30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40$20 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% After deductible Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible

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% - After deductible 4020% - After deductible Hospital based clinic visits 0% - After deductible 40$40 20% - After deductible Pediatric clinic visits 0% - After deductible 40visit PCP practices with PCMH model of care $20 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40does not practice with PCMH model of care $30 20% - After deductible 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible 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. 0% - After deductible 40$40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0$30 20% - After deductible 40Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits visit: PCP practices with PCMH model of care 0% - After deductible 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visitscalls. PCP practices with PCMH model of care 0% - After deductible 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible Covered Benefits Specialists - 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 Specialists Office office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

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% 40% - After deductible Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% 40% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible $50 40% - After deductible 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 Pediatric clinic visit PCP practices with PCMH model of care $20 40% - After deductible PCP does not practice with PCMH model of care $40 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 40% - After deductible PCP does not practice with PCMH model of care $40 40% - After deductible Retail clinics $40 40% - After deductible 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. 0% - After deductible $50 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible $40 40% - After deductible Organ transplant services 020% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible

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% 20% - After deductible 40Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 20% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40$50 20% - After deductible 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 Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $40 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $40 20% - After deductible Retail clinics $40 20% - After deductible 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. 0% - After deductible 40$50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40$40 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 4020% - After deductible

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% - After deductible 4020% - After deductible Hospital based clinic visits 0% - After deductible 40$50 20% - After deductible Pediatric clinic visits 0% - After deductible 40visit PCP practices with PCMH model of care $20 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40does not practice with PCMH model of care $40 20% - After deductible 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $40 20% - After deductible Retail clinics $40 20% - After deductible 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. 0% - After deductible 40$50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0$40 20% - After deductible 40Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 4020% - After deductible

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible 4020% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40$50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0PCP practices with PCMH model of care $0 20% - After deductible 40PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers NonCare Coordinated by Your Primary Care Provider and permitted Self-network Providers Referrals Flex Plan (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 physical therapy visits and 30 occupational therapy visits per plan year. 20% - After deductible 4020% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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% 40% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 40% - After deductible Hospital based clinic visits $30 40% - After deductible Pediatric clinic visit PCP practices with PCMH model of care $10 40% - After deductible PCP does not practice with PCMH model of care $20 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $10 40% - After deductible PCP does not practice with PCMH model of care $20 40% - After deductible Retail clinics $20 40% - After deductible 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. 0% - After deductible $30 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible $20 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible

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% - After deductible 4020% - After deductible Hospital based clinic visits 0% - After deductible 4020% - After deductible Pediatric clinic visits visit 0% - After deductible 4020% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visitscalls. 0% - After deductible 4020% - After deductible Retail clinics 0% - After deductible 4020% - After deductible 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 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. 0% - After deductible 4020% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 4020% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 4020% - After deductible

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% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits vistis 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 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. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ transplant services 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visitsofficevisits.) Allergy injections - Applies to injection only, including administration. 0$0 20% - After deductible 40Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 20% - After deductible Hospital based clinic visits 0$30 20% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $20 20% - After deductible Retail clinics $20 20% - After deductible 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. 0% - After deductible 40$30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40$20 20% - After deductible Organ transplant services 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% After deductible Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible