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 Hospital based clinic visits $25 20% - After deductible Pediatric clinic visit $15 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $15 20% - After deductible Retail clinics $15 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. $25 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $15 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - 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 Hospital based clinic visits $25 20% - After deductible Pediatric clinic visit $15 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $15 20% - After deductible Retail clinics $15 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. $25 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $15 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - 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 Hospital based clinic visits $25 2050 40% - After deductible Pediatric clinic visit $15 2030 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $15 2030 40% - After deductible Retail clinics $15 2030 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. $25 2050 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. $15 2030 40% - After deductible Organ transplant services 020% - After deductible 2040% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 2040% - After deductible