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 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 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 45 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $30 35 Not Covered Enhanced $15 20 Not Covered Retail clinics $30 35 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 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $15 20 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 45 Not Covered

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 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