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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible Not Covered Retail clinics 0% - 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. 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered
Appears in 2 contracts
Samples: Subscriber Agreement, Subscriber Agreement
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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 010% - After deductible Not Covered Hospital based clinic visits 010% - After deductible 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 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 10% - After deductible Not Covered PCP does not practice with PCMH model of care 10% - After deductible Not Covered Retail clinics 010% - 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. 010% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 010% - After deductible Not Covered Organ Transplants Organ transplant services 010% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 010% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
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 Not Covered Diabetic Office Visits office visits Podiatrist Services services - First first routine visit in a plan year 0% - After deductible Not Covered Vision Care Services care services - first routine eye exam in a plan year that includes a retinal eye exam. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible Not Covered Retail clinics 0% - 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. 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
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% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% Hospital based clinic visits $40 - After deductible Not Covered Vision Care Covered Benefits - See Covered Healthcare Services - first routine eye exam for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in a plan year that includes a retinal eye examSection 5 for more information. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% PCP practices with PCMH model of care $15 - After deductible Not Covered PCP does not practice with PCMH model of care $35 - After deductible Not Covered Retail clinics 0% $40 - 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. 0% $40 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% $35 - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% $40 - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 040% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered 40% - After deductible Pediatric clinic 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 Not Covered 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible Not Covered 40% - 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. 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 040% - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 040% - After deductible Not Covereddeductible
Appears in 1 contract
Samples: Subscriber Agreement
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% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 010% - After deductible Not Covered Hospital based clinic visits 0% - After deductible $45 Not Covered Covered Benefits- See Covered Healthcare Services for 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. 0% - After deductible PCP practices with PCMH model of care $15 Not Covered PCP does not practice with PCMH model of care $35 Not Covered Retail clinics 0% - After deductible $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 $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible $35 Not Covered Organ Transplants Organ transplant services 010% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 010% - After deductible Not CoveredCovered Prescription Drugsand Diabetic Equipment and Supplies
Appears in 1 contract
Samples: Subscriber Agreement
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% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 010% - After deductible Not Covered Hospital based clinic visits 0% - After deductible $60 Not Covered Covered Benefits- See Covered Healthcare Services for 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. 0% - After deductible PCP practices with PCMH model of care $20 Not Covered PCP does not practice with PCMH model of care $30 Not Covered Retail clinics 0% - After deductible $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 $60 Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible $30 Not Covered Organ Transplants Organ transplant services 010% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 010% - After deductible Not CoveredCovered Prescription Drugsand Diabetic Equipment and Supplies
Appears in 1 contract
Samples: Subscriber Agreement