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 officevisits.) 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 $30 20% - After deductible Pediatric clinic visit PCP practices with PCMH model of care $10 20% - After deductible PCP does not practice with PCMH model of care $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 $10 20% - After deductible PCP does not practice with PCMH model of care $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. $30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $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 officevisitsoffice visits.) 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 0% 20% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 20- After deductible Not Covered Hospital based clinic visits 0% - After deductible Hospital based clinic visits $30 20% - After deductible Pediatric clinic visit PCP practices with PCMH model of care $10 20% - After deductible PCP does not practice with PCMH model of care $20 20% - After deductible Not Covered 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 $10 200% - After deductible PCP does not practice with PCMH model of care $20 20Not Covered Retail clinics 0% - After deductible Retail clinics $20 20% - 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. $30 200% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 200% - After deductible Not Covered Organ transplant services 0% - After deductible 20% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 200% - After deductible 40% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductibleNot Covered

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive officevisitsoffice visits.) Allergy injections - Applies 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 Not Covered Diabetic Office Visits office visits Podiatrist Services services - First first routine visit in a plan year 0% 20% - After deductible Not Covered Vision Care Services care services - first routine eye exam in a plan year that includes a retinal eye exam. 0% 20- After deductible Not Covered Hospital based clinic visits 0% - After deductible Hospital based clinic visits $30 20% - After deductible Pediatric clinic visit PCP practices with PCMH model of care $10 20% - After deductible PCP does not practice with PCMH model of care $20 20% - After deductible Not Covered 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 $10 200% - After deductible PCP does not practice with PCMH model of care $20 20Not Covered Retail clinics 0% - After deductible Retail clinics $20 20% - 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. $30 200% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 200% - After deductible Not Covered Organ transplant services 0% - After deductible 20% - After deductible Not Covered 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 deductibleNot Covered