Common use of Podiatric Services Clause in Contracts

Podiatric Services. Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment. • Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year. • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Covered subject to the lesser of GHC’s charge or the applicable Copayment. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year. • Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation • Individual/group counseling Covered in full when received through the GHC-designated tobacco cessation program. • Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service.

Podiatric Services. Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment. Annual Deductible and Plan Coinsurance do not apply to office visits, but do apply to office based procedures and surgical services. • Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment in full when in accordance with the well care schedule established by GHCGHC and the Patient Protection and Affordable Care Act of 2010. Not subject to the annual Deductible or any applicable Plan Coinsurance. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Services provided during a preventive care visit which are not in accordance with the well care schedule may be subject to the lesser of GHC’s charge or the applicable outpatient services Cost Share. Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days per calendar yearyear after the annual Deductible is satisfied. • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Annual Deductible and Plan Coinsurance do not apply to office visits, but do apply to office based procedures and surgical services. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar yearyear after the annual Deductible is satisfied. Sterilization (vasectomy, tubal ligation) Covered subject to the lesser of GHC’s charge or the applicable CopaymentCost Share. Annual Deductible and Plan Coinsurance do not apply to office visits, but do apply to office based procedures and surgical services. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member per calendar yearyear after the annual Deductible is satisfied. Annual Deductible and Plan Coinsurance do not apply to office visits, but do apply to office based procedures and surgical services. • Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation • Individual/group counseling Covered in full when sessions received through the GHC-designated tobacco cessation programprogram Covered in full. • Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service.

Podiatric Services.  Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment. •  Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services •  Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year. •  Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Covered subject to the lesser of GHC’s charge or the applicable Copayment. Temporomandibular Joint (TMJ) Services •  Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year. •  Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation •  Individual/group counseling Covered in full when received through the GHC-designated tobacco cessation program. •  Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service.

Podiatric Services. Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment. • Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHC. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year. • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Covered subject to the lesser of GHC’s charge or the applicable CopaymentCopayments. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year. • Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation • Individual/group counseling sessions Covered in full when received through the GHC-designated tobacco cessation programfull. • Approved pharmacy products Covered in full for each thirty (30) day supply or less of a prescription or refill when prescribed as part of the GHC-designated tobacco cessation program by a GHC Provider and dispensed through the GHC-designated mail order serviceobtained at a GHC Facility.

Podiatric Services. Medically Necessary foot care Covered subject to the lesser of GHC’s charge or the applicable Copayment. • Foot care (routine) Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment when in accordance with the well care schedule established by GHCGHC . Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable inpatient services Copayment for up to sixty (60) days per calendar year. • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under Covered subject to the lesser of GHC’s charge or the applicable outpatient services Copayment for up to sixty (60) visits per calendar year. Sexual Dysfunction Services Not covered. Skilled Nursing Facility (SNF) Covered up to sixty (60) days per Member per calendar year. Sterilization (vasectomy, tubal ligation) Covered subject to the lesser of GHC’s charge or the applicable Copayment. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services Covered subject to the lesser of GHC’s charge or the applicable Copayment up to $1,000 maximum per Member per calendar year. • Lifetime benefit maximum Covered up to $5,000 per Member. Tobacco Cessation • Individual/group counseling Covered in full when sessions received through the GHC-designated tobacco cessation programprogram Covered in full. • Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC-designated mail order service.