Common use of See Prevention and Early Detection Services Clause in Contracts

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 Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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 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. Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $50 20% - After deductible Organ Transplants 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 Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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 Hospital based clinic visits $50 30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 20 20% - After deductible Retail clinics $30 20 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. $50 30 20% - After deductible Organ Transplants 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 Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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 Hospital based clinic visits $50 40 20% - 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 $30 0 20% - After deductible PCP does not practice with PCMH model of care $25 20% - After deductible Retail clinics $30 25 20% - After deductible Specialists - office Office visits and house calls rendered by a specialist. Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. See below for behavioral health specialist. $50 40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $25 20% - After deductible Organ Transplants 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 Physical/Occupational Therapy 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 Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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 Hospital based clinic visits $50 40 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 $30 0 20% - After deductible PCP does not practice with PCMH model of care $25 20% - After deductible Retail clinics $30 25 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. Please see Preauthorization in Section 5 for more information. You Pay You Pay Specialists - office visits and house calls rendered by a specialist. Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $50 40 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible