Common use of Preventative Care Clause in Contracts

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No copayment No Copayment No Copayment $ 10 Copay No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance $ 10 copay $ 10 Copay No charge No charge No charge $ 10 initial visit only $ 10 copay (unlimited) Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No charge No charge No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered $ 10 per visit $ 50 per visit No charge $ 25 per visit Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered

Preventative Care. Physical Examination - Child Physical Examination - Adult Vision Examination / one every two years OB/GYN visit Mammography Hearing Screening / One every year years No copayment No Copayment No Copayment $ 15 Copay No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No copayment No Copayment No Copayment $ 10 Copay No Copayment No Copayment No copayment No Copayment No Copayment No Copayment No Copayment No Copayment Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance OUTPATIENT CARE: Physician Office Visit Specialist Office Visit Outpatient Surgical Services Diagnostic X-Ray / Lab Examination Complex Imaging (MRI, CAT, PET, etc ) Prenatal and Postnatal Maternity Care Outpatient Rehabilitation $ 15 copay $ 15 copay $ 50 per visit No charge No charge $ 15 initial visit only No Charge (50 visit max) Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance $ 10 copay $ 10 Copay No charge No charge No charge $ 10 initial visit only $ 10 copay (unlimited) Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance MENTAL HEALTH CARE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance SUBSTANCE ABUSE: Outpatient Treatment Inpatient Treatment $ 15 copay $100 per admission Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance ALLERGY CARE: Office Visit Injections $ 15 copay No charge Deductible & Coinsurance Deductible & Coinsurance $ 10 copay No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOSPITAL CARE: Semi Private Hospital Admission Skilled Nursing and Rehabilitation Facilities Rehabilitative services $100 per admission $100 per admission No charge Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance No charge No charge No charge Subject to Deductible Subject to Deductible Deductible & Coinsurance Deductible & Coinsurance HOME HEALTH CARE: No charge $50 Ded & Coinsurance No charge Subject to Deductible Deductible & Coinsurance EMERGENCY CARE: Walk-in Center Emergency Room (waived fee if admitted) Ambulance Service Urgent Care $ 15 per visit $ 50 per visit No charge $ 25 per visit Deductible & Coinsurance $ 50 per visit No charge Not covered $ 10 per visit $ 50 per visit No charge $ 25 per visit Subject to Deductible Subject to Deductible Subject to Deductible Subject to Deductible Deductible & Coinsurance Same as In-network Same as In-network Not Covered