Common use of PRIMARY CARE OFFICE VISITS Clause in Contracts

PRIMARY CARE OFFICE VISITS. This plan allows the designation of a Primary Care Provider (PCP). You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your PCP and telling us the name of the PCP any time prior to an office visit. You have the right to designate any PCP in the network. Each member can select a different PCP. Children can select a pediatrician. Your PCP must be one of the following provider types:  Family practice physician  General practice physician  Geriatric practice provider  Gynecologist  Internist  Naturopath  Nurse practitioner  Obstetrician  Pediatrician  Physician Assistant You do not need a referral from your PCP or any other person authorizing access to specialty care. This includes but is not limited to gynecologists and obstetricians. However, there may be services provided by the specialist that require prior authorization. Please see Prior Authorization for details. We encourage you to select a PCP at the time you enroll in this plan. If you have difficulty locating an available PCP, contact us and we will help you in selecting one. If you do not choose a PCP, we may assign as your PCP a provider you have previously seen. You may change this PCP selection by contacting us. If your PCP is part of a group practice, you can see any provider type listed above in that practice, and receive the PCP office visit copay. You can change your PCP selection at any time by contacting us, but the change will be effective the first of the next month. If you need to see your PCP and your PCP is not available, you may see a PCP within the same clinic and you will only be responsible for the lower cost share. If your PCP is a sole practitioner, you may see a PCP that your provider has asked to cover in their absence. You will only be responsible for the lower copay. Please call Customer Service for more information about selecting a PCP and to provide us with your selection. All other covered services provided by your selected PCP during the primary care office visit are subject to standard cost shares. For example, if you select a PCP and see that PCP for a cut that needs stitches, you will pay the lower copayment amount for the office visit and will pay your plan’s deductible and/or coinsurance for the stitching procedure. If you do not select a PCP, your office visit copay will be the higher copayment amount. See the Summary of Your Costs and Covered Services for details. CALENDAR YEAR DEDUCTIBLE A calendar year deductible is the amount of expense you must incur in each calendar year for covered services and supplies before this plan provides benefits. If an out-of-network provider is covered at the in-network level as described below in How Providers Affect Your Costs, the in-network deductible applies. See the Summary of Your Costs for your deductible amounts. Deductibles are subject to the following:  Deductibles accrue during a calendar year and begin each year on January 1  There is no carry over provision. Xxxxxxx credited to your deductible during the current year will not carry forward to the next year’s deductible  Xxxxxxx credited to the deductible will not exceed the allowed amount  Copayments are not applied to the deductible  Xxxxxxx credited toward the deductible do not add to benefits with a dollar maximum  Xxxxxxx credited toward the deductible accrue to benefits with visit limits Amounts that don’t accrue toward the deductible are:  Amounts that exceed the allowed amount  Charges for excluded services

PRIMARY CARE OFFICE VISITS. This plan allows the designation of a Primary Care Provider (PCP). You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your PCP and telling us the name of the PCP any time prior to an office visit. You have the right to designate any PCP in the network. Each member can select a different PCP. Children can select a pediatrician. Your PCP must be one of the following provider types:  • Family practice physician  • General practice physician  • Geriatric practice provider  • Gynecologist  • Internist  • Naturopath  • Nurse practitioner  • Obstetrician  • Pediatrician  • Physician Assistant You do not need a referral from your PCP or any other person authorizing access to specialty care. This includes but is not limited to gynecologists and obstetricians. However, there may be services provided by the specialist that require prior authorization. Please see Prior Authorization for details. We encourage you to select a PCP at the time you enroll in this plan. If you have difficulty locating an available PCP, contact us and we will help you in selecting one. If you do not choose a PCP, we may assign as your PCP a provider you have previously seen. You may change this PCP selection by contacting us. If your PCP is part of a group practice, you can see any provider type listed above in that practice, and receive the PCP office visit copay. You can change your PCP selection at any time by contacting us, but the change will be effective the first of the next month. If you need to see your PCP and your PCP is not available, you may see a PCP within the same clinic and you will only be responsible for the lower cost share. If your PCP is a sole practitioner, you may see a PCP that your provider has asked to cover in their absence. You will only be responsible for the lower copay. Please call Customer Service for more information about selecting a PCP and to provide us with your selection. Urgent care, telehealth, preventive and specialty visits are not included. All other covered services provided by your selected PCP during the primary care office visit are subject to standard cost shares. For example, if you select a PCP and see that PCP for a cut that needs stitches, you will pay the lower copayment amount for the office visit and will pay your plan’s deductible and/or coinsurance for the stitching procedure. If you do not select a PCP, your office visit copay will be the higher copayment amount. See the Summary of Your Costs and Covered Services for details. CALENDAR YEAR DEDUCTIBLE A calendar year deductible is the amount of expense you must incur in each calendar year for covered services and supplies before this plan provides benefits. If an out-of-network provider is covered at the in-network level as described below in How Providers Affect Your Costs, the in-network deductible applies. See the Summary of Your Costs for your deductible amounts. Deductibles are subject to the following:  • Deductibles accrue during a calendar year and begin each year on January 1  • There is no carry over provision. Xxxxxxx credited to your deductible during the current year will not carry forward to the next year’s deductible  • Xxxxxxx credited to the deductible will not exceed the allowed amount  • Copayments are not applied to the deductible  • Xxxxxxx credited toward the deductible do not add to benefits with a dollar maximum  • Xxxxxxx credited toward the deductible accrue to benefits with visit limits Amounts that don’t accrue toward the deductible are:  • Amounts that exceed the allowed amount  • Charges for excluded services

PRIMARY CARE OFFICE VISITS. This plan allows the designation of a Primary Care Provider (PCP). You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your PCP and telling us the name of the PCP any time prior to an office visit. You have the right to designate any PCP in the network. Each member can select a different PCP. Children can select a pediatrician. Your PCP must be one of the following provider types:  Family practice physician  General practice physician  Geriatric practice provider  Gynecologist  Internist  Naturopath  Nurse practitioner  Obstetrician  Pediatrician  Physician Assistant You do not need a referral from your PCP or any other person authorizing access to specialty care. This includes but is not limited to gynecologists and obstetricians. However, there may be services provided by the specialist that require prior authorization. Please see Prior Authorization for details. We encourage you to select a PCP at the time you enroll in this plan. If you have difficulty locating an available PCP, contact us and we will help you in selecting one. If you do not choose a PCP, we may assign as your PCP a provider you have previously seen. You may change this PCP selection by contacting us. If your PCP is part of a group practice, you can see any provider type listed above in that practice, and receive the PCP office visit copay. You can change your PCP selection at any time by contacting us, but the change will be effective the first of the next month. If you need to see your PCP and your PCP is not available, you may see a PCP within the same clinic and you your will only be responsible for the lower cost share. If your PCP is a sole practitioner, you may see a PCP that your provider has asked to cover in their absence. You will only be responsible for the lower copay. Please call Customer Service for more information about selecting a PCP and to provide us with your selection. Urgent care, telehealth, preventive and specialty visits are not included. All other covered services provided by your selected PCP during the primary care office visit are subject to standard cost shares. For example, if you select a PCP and see that PCP for a cut that needs stitches, you will pay the lower copayment amount for the office visit and will pay your plan’s deductible and/or coinsurance for the stitching procedure. If you do not select a PCP, your office visit copay will be the higher copayment amount. See the Summary of Your Costs and Covered Services for details. CALENDAR YEAR DEDUCTIBLE A calendar year deductible is the amount of expense you must incur in each calendar year for covered services and supplies before this plan provides benefits. If an out-of-network provider is covered at the in-network level as described below in How Providers Affect Your Costs, the in-network deductible applies. See the Summary of Your Costs for your deductible amounts. Deductibles are subject to the following:  Deductibles accrue during a calendar year and begin each year on January 1  There is no carry over provision. Xxxxxxx credited to your deductible during the current year will not carry forward to the next year’s deductible  Xxxxxxx credited to the deductible will not exceed the allowed amount  Copayments are not applied to the deductible  Xxxxxxx credited toward the deductible do not add to benefits with a dollar maximum  Xxxxxxx credited toward the deductible accrue to benefits with visit limits Amounts that don’t accrue toward the deductible are:  Amounts that exceed the allowed amount  Charges for excluded services.

PRIMARY CARE OFFICE VISITS. This plan allows the designation of a Primary Care Provider (PCP). You can receive the lower copayment amount on primary care office visit copays by selecting a provider as your PCP and telling us the name of the PCP any time prior to an office visit. You have the right to designate any PCP in the network. Each member can select a different PCP. Children can select a pediatrician. Your PCP must be one of the following provider types:  Family practice physician  General practice physician  Geriatric practice provider  Gynecologist  Internist  Naturopath  Nurse practitioner  Obstetrician  Pediatrician  Physician Assistant You do not need a referral from your PCP or any other person authorizing access to specialty care. This includes but is not limited to gynecologists and obstetricians. However, there may be services provided by the specialist that require prior authorization. Please see Prior Authorization for details. We encourage you to select a PCP at the time you enroll in this plan. If you have difficulty locating an available PCP, contact us and we will help you in selecting one. If you do not choose a PCP, we may assign as your PCP a provider you have previously seen. You may change this PCP selection by contacting us. If your PCP is part of a group practice, you can see any provider type listed above in that practice, and receive the PCP office visit copay. You can change your PCP selection at any time by contacting us, but the change will be effective the first of the next month. If you need to see your PCP and your PCP is not available, you may see a PCP within the same clinic and you will only be responsible for the lower cost share. If your PCP is a sole practitioner, you may see a PCP that your provider has asked to cover in their absence. You will only be responsible for the lower copay. Please call Customer Service for more information about selecting a PCP and to provide us with your selection. Urgent care, telehealth, preventive and specialty visits are not included. All other covered services provided by your selected PCP during the primary care office visit are subject to standard cost shares. For example, if you select a PCP and see that PCP for a cut that needs stitches, you will pay the lower copayment amount for the office visit and will pay your plan’s deductible and/or coinsurance for the stitching procedure. If you do not select a PCP, your office visit copay will be the higher copayment amount. See the Summary of Your Costs and Covered Services for details. CALENDAR YEAR DEDUCTIBLE A calendar year deductible is the amount of expense you must incur in each calendar year for covered services and supplies before this plan provides benefits. If an out-of-network provider is covered at the in-network level as described below in How Providers Affect Your Costs, the in-network deductible applies. See the Summary of Your Costs for your deductible amounts. Deductibles are subject to the following:  Deductibles accrue during a calendar year and begin each year on January 1  There is no carry over provision. Xxxxxxx credited to your deductible during the current year will not carry forward to the next year’s deductible  Xxxxxxx credited to the deductible will not exceed the allowed amount  Copayments are not applied to the deductible  Xxxxxxx credited toward the deductible do not add to benefits with a dollar maximum  Xxxxxxx credited toward the deductible accrue to benefits with visit limits Amounts that don’t accrue toward the deductible are:  Amounts that exceed the allowed amount  Charges for excluded services