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% 20% - After deductible Diabetic 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 $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. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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 Diabetic 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% 2040% - After deductible Hospital based clinic visits $50 40% - After deductible Pediatric clinic visit PCP practices with PCMH model of care $20 40% - After deductible PCP does not practice with PCMH model of care $40 2040% - 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 2040% - After deductible PCP does not practice with PCMH model of care $30 2040 40% - After deductible Retail clinics $30 2040 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. $40 2050 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 2040 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 2040% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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% 20% - After deductible (*) 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% 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 $40 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 Pediatric clinic visit PCP practices with PCMH model of care $20 10 20% - After deductible PCP does not practice with PCMH model of care $30 20 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 10 20% - After deductible PCP does not practice with PCMH model of care $30 20 20% - After deductible Retail clinics $30 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. $40 30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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% 20% - After deductible Diabetic 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 $40 20% - After deductible 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 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. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - 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 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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 Diabetic 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 $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 $30 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 $30 40 20% - After deductible Retail clinics $30 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. $40 50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 40 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 20% - 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 Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% $0 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% $0 20% - After deductible Hospital based clinic visits $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 callscalls and pediatric clinic visits. 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 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. $40 30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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% 2040% - After deductible Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% 2040% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 2040% - After deductible Hospital based clinic visits $40 2050 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 2040% - After deductible PCP does not practice with PCMH model of care $30 2040 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 2040% - After deductible PCP does not practice with PCMH model of care $30 2040 40% - After deductible Retail clinics $30 2040 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. $40 2050 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 2040 40% - After deductible Organ transplant services 020% - After deductible 2040% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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 Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% Hospital based clinic visits $50 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible Hospital based clinic visits PCP does 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 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 40 20% - After deductible Retail clinics $30 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. $40 50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 40 20% - 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 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 20% - 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 Diabetic 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 $40 2040% - 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 $20 2010 40% - After deductible PCP does not practice with PCMH model of care $30 2020 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 2010 40% - After deductible PCP does not practice with PCMH model of care $30 2020 40% - After deductible Retail clinics $30 2020 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. $40 2030 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 2020 40% - After deductible Organ transplant services 0% - After deductible 2040% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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% 20% - After deductible Diabetic Office Visits office visits: Podiatrist Services services - First first routine visit in a plan year 0% 20% - After deductible Vision Care Services care services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 20% - After deductible Hospital based clinic visits $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 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 First non-preventive visits rendered by a PCP in the plan year. $0 20% - After deductible Subsequent non-preventive visits rendered by a PCP in the plan year. $20 20% - After deductible PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year. $0 20% - After deductible Subsequent non-preventive visits rendered by a PCP in the plan year. $30 20% - After deductible Retail clinics $30 20% - After deductible 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. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible