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. 10% - After deductible Not Covered Hospital based clinic visits 10% - After deductible 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 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% - After deductible Not Covered PCP does not practice with PCMH model of care 10% - After deductible Not Covered Retail clinics 10% - 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. 10% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. 10% - After deductible Not Covered Organ Transplants Organ transplant services 10% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
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. 10% - After deductible Not Covered Hospital based clinic visits 10% - After deductible $45 Not Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) 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% - After deductible $15 Not Covered PCP does not practice with PCMH model of care 10% - After deductible $35 Not Covered Retail clinics 10% - After deductible $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. 10% - After deductible $45 Not Covered Office visits and house calls rendered by a behavioral health specialist. 10% - After deductible $35 Not Covered Organ Transplants Organ transplant services 10% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not CoveredCovered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 10% - After deductible Not Covered Prescription Drugsand Diabetic Equipment and Supplies
Appears in 1 contract
Samples: Subscriber Agreement
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. 10% - After deductible Not Covered Hospital based clinic visits 10% - After deductible $60 Not Covered Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) 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% - After deductible $20 Not Covered PCP does not practice with PCMH model of care 10% - After deductible $30 Not Covered Retail clinics 10% - After deductible $50 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. 10% - After deductible $60 Not Covered Office visits and house calls rendered by a behavioral health specialist. 10% - After deductible $30 Not Covered Organ Transplants Organ transplant services 10% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not CoveredCovered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 10% - After deductible Not Covered Prescription Drugsand Diabetic Equipment and Supplies
Appears in 1 contract
Samples: Subscriber Agreement
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. 10% - After deductible $0 Not Covered Hospital based clinic visits 10% $40 Not Covered PCP visits - After deductible including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $25 Not Covered Retail clinics $25 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 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% - After deductible Not Covered PCP does not practice with PCMH model of care 10% - After deductible Not Covered Retail clinics 10% - 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. 10% - After deductible $40 Not Covered Office visits and house calls rendered by a behavioral health specialist. 10% $25 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 100% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 1020% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement