Common use of Observation Services Clause in Contracts

Observation Services. In a hospital or other health care facility 10% - After deductible Not Covered Allergy injections - Applies to injection only, including administration. 10% - After deductible Not Covered Hospital based clinic visits $45 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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 $10 Not Covered PCP does not practice with PCMH model of care $20 Not Covered Retail clinics $45 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. $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered

Observation Services. In a hospital or other health care facility 10% - After deductible Not Covered Allergy injections - Applies to injection only, including administration. 10% - After deductible Not Covered Hospital based clinic visits $45 30 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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 $10 15 Not Covered PCP does not practice with PCMH model of care $20 25 Not Covered Retail clinics $45 30 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. $45 30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $20 25 Not Covered Organ transplant services 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered