Common use of Outpatient Care Clause in Contracts

Outpatient Care. We cover the following outpatient care: • Primary care visits for internal medicine, family practice, pediatrics, and routine preventive obstetrics/gynecology Services (refer to “Preventive Health Care Services” for coverage of preventive care Services); • Specialty care visits (refer to “Referrals to Plan Providers” in the “How to Obtain Services” section for information about referrals to Plan specialists); • Consultations and immunizations for foreign travel; • Diagnostic testing for care or treatment of an illness; or to screen for a disease for which you have been determined to be at high risk for contracting. This includes, but is not limited to: • Diagnostic exams, including digital rectal exams and prostate antigen (PSA) tests provided: • to persons age 40 and over; who are at high risk for prostate cancer according to the most recent published guidelines of the American Cancer Society; • Colorectal cancer screening, specifically: screening with an annual fecal occult blood test; flexible sigmoidoscopy or colonoscopy; or, when appropriate, radiologic imaging, for persons, who are at high risk of cancer. High risk is determined based on the most recently published guidelines of the American College of Gastroenterology, in consultation with the American Cancer Society; • Bone mass measurement for the prevention, diagnosis, and treatment of osteoporosis for a qualified individual when a Plan Provider requires the bone mass measurement. A “qualified individual” means: • an estrogen deficient person at clinical risk for osteoporosis; • a person with a specific sign suggestive of spinal osteoporosis. This includes: roentgeno-graphic osteopenia or roentgenographic evidence suggestive of collapse; wedging; or ballooning of one or more thoracic or lumbar vertebral bodies; and who is a candidate for therapeutic intervention or for an extensive diagnostic evaluation for metabolic bone disease; • a person receiving long-term gluco- corticoid (steroid) therapy; • a person with primary hyper- parathyroidsm; or • a person being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy; (Refer to “Preventive Health Services” for coverage of preventive care tests and screening Services); • Outpatient surgery; • Anesthesia; including Services of an anesthesiologist; • Chemotherapy and radiation therapy; • Respiratory therapy; • Medical social Services; • House calls when care can best be provided in your home as determined by a Plan Provider; • After hours urgent care received after the regularly scheduled hours of the Plan Provider or Plan Facility. Refer to the Urgent Care provision for covered Services. Additional outpatient Services are covered, but only as described in this “Benefits” section, subject to all the limits and exclusions for that Service.

Outpatient Care. We cover the following outpatient care: •  Primary care visits for internal medicine, family practice, pediatrics, and routine preventive obstetrics/gynecology Services (refer to “Preventive Health Care Services” for coverage of preventive care Services); •  Specialty care visits (refer to “Referrals to Plan Providers” in the “How to Obtain Services” section for information about referrals to Plan specialists); •  Consultations and immunizations for foreign travel; •  Diagnostic testing for care or treatment of an illness; or to screen for a disease for which you have been determined to be at high risk for contracting. This includes, but is not limited to: •  Diagnostic exams, including digital rectal exams and prostate antigen (PSA) tests provided: •  to persons age 40 and over; who are at high risk for prostate cancer according to the most recent published guidelines of the American Cancer Society; •  Colorectal cancer screening, specifically: screening with an annual fecal occult blood test; flexible sigmoidoscopy or colonoscopy; or, when appropriate, radiologic imaging, for persons, who are at high risk of cancer. High risk is determined based on the most recently published guidelines of the American College of Gastroenterology, in consultation with the American Cancer Society; •  Bone mass measurement for the prevention, diagnosis, and treatment of osteoporosis for a qualified individual when a Plan Provider requires the bone mass measurement. A “qualified individual” means: •  an estrogen deficient person at clinical risk for osteoporosis; •  a person with a specific sign suggestive of spinal osteoporosis. This includes: roentgeno-graphic osteopenia or roentgenographic evidence suggestive of collapse; wedging; or ballooning of one or more thoracic or lumbar vertebral bodies; and who is a candidate for therapeutic intervention or for an extensive diagnostic evaluation for metabolic bone disease; •  a person receiving long-term gluco- corticoid (steroid) therapy; •  a person with primary hyper- parathyroidsm; or •  a person being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy; (Refer to “Preventive Health Services” for coverage of preventive care tests and screening Services); •  Outpatient surgery; •  Anesthesia; including Services of an anesthesiologist; •  Chemotherapy and radiation therapy; •  Respiratory therapy; •  Medical social Services; •  House calls when care can best be provided in your home as determined by a Plan Provider; •  After hours urgent care received after the regularly scheduled hours of the Plan Provider or Plan Facility. Refer to the Urgent Care provision for covered Services. Additional outpatient Services are covered, but only as described in this “Benefits” section, subject to all the limits and exclusions for that Service.

Outpatient Care. We cover the following outpatient care: • Primary care visits for internal medicine, family practice, pediatrics, and routine preventive obstetrics/gynecology Services (refer to “Preventive Health Care Services” for coverage of preventive care Services); • Specialty care visits (refer to “Referrals to Plan Providers” in the “How to Obtain Services” section for information about referrals to Plan specialists); • Consultations and immunizations for foreign traveltravel (refer to “Outpatient Prescription Drugs Rider,” attached to this EOC, for coverage of self- administered travel vaccines); • Diagnostic testing for care or treatment of an illness; , or to screen for a disease for which you have been determined to be at high risk for contracting. This includes, including, but is not limited to: • Diagnostic examsexaminations, including digital rectal exams and prostate antigen (PSA) tests provided: • to persons age 40 and over; over who are at high risk for prostate cancer according to the most recent published guidelines of the American Cancer Society; • Colorectal cancer screening, specifically: specifically screening with an annual fecal occult blood test; , flexible sigmoidoscopy or colonoscopy; or, when appropriate, or in appropriate circumstances radiologic imaging, for persons, who are at high risk of cancer. High risk is determined based on , in accordance with the most recently published guidelines of the American College of Gastroenterology, in consultation with the American Cancer Society; • Bone mass measurement for the prevention, diagnosis, and treatment of osteoporosis for a qualified individual when a Plan Provider requires the bone mass measurement. A “qualified individual” means: means • an estrogen deficient person individual at clinical risk for osteoporosis; • a person an individual with a specific sign suggestive of spinal osteoporosis. This includes: , including roentgeno-graphic osteopenia or roentgenographic evidence suggestive of collapse; , wedging; , or ballooning of one or more thoracic or lumbar vertebral bodies; and , who is a candidate for therapeutic intervention or for an extensive diagnostic evaluation for metabolic bone disease; • a person an individual receiving long-term gluco- corticoid (steroid) therapy; • a person an individual with primary hyper- parathyroidsm; or • a person an individual being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy; therapy (Refer to “Preventive Health Services” for coverage of preventive care tests and screening Services); • Outpatient surgery; • Anesthesia; including Services of an anesthesiologist; • Chemotherapy and radiation therapy; • Respiratory therapy; • Medical social Services; • House calls when care can best be provided in your home as determined by a Plan Provider; • After hours urgent care received after the regularly scheduled hours of the Plan Provider or Plan Facility. Refer to the Urgent Care provision for covered Services. Additional outpatient Services are covered, but only as specifically described in this “Benefits” section, subject to all the limits and exclusions for that Service.