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 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 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 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 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% - 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
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 $40 20% - After deductible 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 Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $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. $40 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 Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible
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 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 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% - 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
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% Not Covered Hospital based clinic visits $25 - After deductible Not Covered Pediatric clinic visit $15 - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $15 - After deductible Not Covered Retail clinics $15 - 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. $25 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 - 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
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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $30 Not Covered Enhanced $15 Not Covered Retail clinics $30 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. $40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. $40 Not Covered
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. 30% - After deductible Not Covered Diabetic office visits: Podiatrist services - first routine visit in a plan year 0% Not Covered Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. 0% Not Covered Hospital based clinic visits $65 Not Covered Pediatric clinic visit: PCP practices with PCMH model of care $40 Not Covered PCP does not practice with PCMH model of care $60 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls: PCP practices with PCMH model of care First non-preventive visits rendered by a PCP in the plan year. $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year. $40 Not Covered PCP does not practice with PCMH model of care First non-preventive visits rendered by a PCP in the plan year. $0 Not Covered Subsequent non-preventive visits rendered by a PCP in the plan year. $60 Not Covered Retail clinics $50 Not Covered Specialists - office visits and house calls rendered by a specialist. Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $65 Not Covered Organ Transplants Organ transplant services 30% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 30% - 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
Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive officevisits.) Allergy injection-sapplies to injection only, including administration. 0% 40%- Afterdeductible Hospitalbased clinic visits $40 40%- Afterdeductible Pediatric clinic visit $25 40%- Afterdeductible PCP visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls. $25 40%- Afterdeductible Retail clinics $25 40%- Afterdeductible Specialists Office visits and house calls rendered by a specialist. Specialistincludes but is not limited to allergists, dermatologists and xxxxxxxxxxXx.xx below for behavioral health specialist. $40 40%- Afterdeductible Office visits and house calls rendered by a behavioral health specialist. $25 40%- Afterdeductible Organ Transplants Organ transplant services 20%- Afterdeductible 40%- Afterdeductible Physical/Occupational Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD Limited to30 physical therapy visits and 30 occupationa therapy visits peprlan year. 20%- Afterdeductible 40%- Afterdeductible
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 $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 $25 Not Covered PCP does not practice with PCMH model of care $45 Not Covered Retail clinics $50 Not Covered Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $60 Not Covered Office visits and house calls rendered by a behavioral health specialist. $45 Not Covered Organ Transplants Organ transplant services 10% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered
Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injection-sapplies to injection only, including administration. $0 20%- Afterdeductible Diabetic office visits: Podiatrist service-s first routine visit inpalan year $0 20%- Afterdeductible Vision care service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 20%- Afterdeductible Hospitalbased clinic visits $40 20%- Afterdeductible PCP visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls and pediatric clinic visits $25 20%- Afterdeductible Retail clinics $25 20%- Afterdeductible Specialists- office visits and house calls rendered by a specialist. Specialist includes but is not limitebdehtoavioral health, allergists, dermatologists and podiatrists. $40 20%- Afterdeductible Organ Transplants Organ transplanstervices 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40%- Afterdeductible
Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injection-sapplies to injection only, including administration. 0%- Afterdeductible 40%- Afterdeductible Hospitalbased clinic visits 0%- Afterdeductible 40%- Afterdeductible PCP visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls and pediatric clinic visit 0%- Afterdeductible 40%- Afterdeductible Retail clinics 0%- Afterdeductible 40%- Afterdeductible Specialists Office visits and house calls rendered by a specialist. Specialistincludes but is not limited to allergists, dermatologists and xxxxxxxxxxXx.xx below for behavioral health specialist. 0%- Afterdeductible 40%- Afterdeductible Office visits and house calls rendered by a behavioral health specialist. 0%- Afterdeductible 40%- Afterdeductible Organ Transplants Organ transplant services 0%- Afterdeductible 40%- Afterdeductible Physical/Occupational Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD Limited to30 physical therapy visits and 30 occupationa therapy visits peprlan year. 0%- Afterdeductible 40%- Afterdeductible
