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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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. 010% - After deductible 40% - After deductible Not Covered 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 $60 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. PCP practices with PCMH model of care $20 Not Covered PCP does not practice with PCMH model of care $30 Not Covered Retail clinics $50 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. 0% - After deductible 40% - After deductible $60 Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible $30 Not Covered Organ Transplants Organ transplant services 010% - After deductible 40% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductibleNot 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. 010% - After deductible 40% - After deductible Not Covered 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 $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. PCP practices with PCMH model of care $15 Not Covered PCP does not practice with PCMH model of care $35 Not Covered Retail clinics $45 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. 0% - After deductible 40% - After deductible $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible $35 Not Covered Organ Transplants Organ transplant services 010% - After deductible 40% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible 40% - After deductibleNot 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% - 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 Transplants Organ transplant services 0% - After deductible 4020% - After deductible Physical/Occupational Therapy 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 Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy 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$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 Transplants Organ transplant services 0% - After deductible 4020% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% After deductible Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible