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 $50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $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. $50 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

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% $0 20% - After deductible Hospital based clinic visits $50 30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $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. $50 30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20 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% $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 Hospital based clinic visits $50 30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $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. $50 30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20 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% $0 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible