See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $15 20% - After deductible Pediatric clinic visit $15 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $15 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Retail clinics $15 20% - After deductible Specialists - office visits and house calls rendered by a specialist. Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $15 20% - After deductible Organ transplant services 0% 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. Limited to 30 physical therapy visits and 30 occupational therapy visits per plan year. 20% 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $40 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $0 20% - After deductible PCP does not practice with PCMH model of care $25 20% - After deductible Retail clinics $25 20% - After deductible Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $25 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient hospital/in a physician’s/therapist’s office. Limited to 30 physical therapy visits and 30 occupational therapy visits per plan year. 20% - After deductible 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $40 20% plus $40 - After deductible Pediatric clinic visit $25 20% plus $25 - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $25 20% plus $25 - After deductible Retail clinics $25 20% plus $25 - After deductible 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 20% plus $40 - After deductible Office visits and house calls rendered by a behavioral health specialist. $25 20% plus $25 - After deductible Organ transplant services 0% - After deductible 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 20% - After deductible Retail clinics $30 20% - After deductible 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. $50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. 0% 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $40 20% plus $40 - After deductible Pediatric clinic visit $25 20% plus $25 - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $25 20% plus $25 - After deductible Retail clinics $25 20% plus $25 - After deductible Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $40 20% plus $40 - After deductible Office visits and house calls rendered by a behavioral health specialist. $25 20% plus $25 - After deductible Organ transplant services 0% - After deductible 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% - After deductible Not Covered Diabetic office visits Podiatrist services - first routine visit in a plan year 0% - After deductible Not Covered Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible Not Covered Retail clinics 0% - After deductible 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. 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. PCP practices with PCMH model of care $0 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible
See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits 0% - After deductible 20% - After deductible Pediatric clinic visit 0% - After deductible 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. 0% - After deductible 20% - After deductible Retail clinics 0% - After deductible 20% - After deductible Specialists Office visits and house calls rendered by a specialist. Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. 0% - After deductible 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible
