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. 10% - After deductible Not Covered Hospital based clinic visits $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. 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. $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible 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. 10% - After deductible Not Covered Hospital based clinic visits $45 60 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. 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 20 Not Covered PCP does not practice with PCMH model of care $35 30 Not Covered Retail clinics $45 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. $45 60 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 30 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible 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. 10% - After deductible $0 Not Covered Hospital based clinic visits $45 40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $25 Not Covered Retail clinics $25 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. 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. $45 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 25 Not Covered 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 Not Covered Organ transplant services 100% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 1020% - After deductible 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. 10% - After deductible Not Covered Hospital based clinic visits $45 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. PCP practices with PCMH model of care $15 10% - After deductible Not Covered PCP does not practice with PCMH model of care $35 10% - After deductible Not Covered Retail clinics $45 10% - After deductible 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. $45 10% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 10% - After deductible Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered

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. 10% - After deductible Not Covered Hospital based clinic visits $45 60 Not Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. 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 20 Not Covered PCP does not practice with PCMH model of care $35 30 Not Covered Retail clinics $45 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. $45 60 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 30 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 10% - After deductible 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. 10% - After deductible $0 Not Covered Hospital based clinic visits $45 50 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 Not Covered Retail clinics $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals 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. 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. $45 50 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 30 Not Covered 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 Not Covered Organ transplant services 100% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 1020% - After deductible Not Covered

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. 10% - After deductible Not Covered Hospital based clinic visits $45 Not Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. 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. $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $35 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 10% - After deductible Not Covered