Common use of Other than Preventive Care Services Clause in Contracts

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 office visits.) Allergy injections - Applies applies to injection only, including administration. 010% - After deductible Not Covered Hospital based clinic visits $25 - After deductible Not Covered Pediatric clinic visit $15 - After deductible 45 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 $15 - After deductible 10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered Retail clinics $15 - After deductible 45 Not Covered 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. $25 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 - After deductible 45 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

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. 010% - After deductible Not Covered Hospital based clinic visits $25 - After deductible Not Covered Pediatric clinic visit $15 - After deductible 60 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 $15 - After deductible 25 Not Covered PCP does not practice with PCMH model of care $45 Not Covered Retail clinics $15 - After deductible 50 Not Covered 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. $25 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 - After deductible 60 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