Common use of Office Visits (other than Preventive Care Services) Clause in Contracts

Office Visits (other than Preventive Care Services). 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 Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Office Visits (other than Preventive Care Services). 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 $0 Not Covered Hospital based clinic visits 0% - After deductible $50 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible $30 Not Covered Retail clinics 0% - After deductible $30 Not Covered 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 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 $50 Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% $30 Not Covered Podiatrist Services - After deductible 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 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 020% - After deductible Not Covered

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visitsofficevisits.) 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% Hospital based clinic visits $40 - After deductible Not Covered Vision Care Covered Benefits - See Covered Healthcare Services - first routine eye exam for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in a plan year that includes a retinal eye examSection 5 for more information. 0% - After deductible Not Covered Hospital based clinic visits 0% - After deductible Not Covered You Pay You Pay PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% PCP practices with PCMH model of care $15 - After deductible Not Covered PCP does not practice with PCMH model of care $35 - After deductible Not Covered Retail clinics 0% $40 - 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% $40 - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 0% $35 - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% $40 - After deductible Not Covered

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible Not Covered Diabetic Office Visits office visits Podiatrist Services services - First first routine visit in a plan year 0% - After deductible Not Covered Vision Care Services 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 Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies applies to injection only, including administration. 0% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year 040% - 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 40% - After deductible Pediatric clinic visit: PCP practices with PCMH model of care 0% - After deductible 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visitscalls. PCP practices with PCMH model of care 0% - After deductible Not Covered 40% - After deductible PCP does not practice with PCMH model of care 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible Not Covered 40% - After deductible Specialists Office - office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 040% - After deductible Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 040% - After deductible Not Covereddeductible