Office Visits (other than Preventive Care Services). This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
Office Visits (other than Preventive Care Services). This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see and whether your primary care provider practices with a patient centered medical home (PCMH) care model that is recognized by us. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
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 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - 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 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 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible
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% 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 Hospital based clinic visits $40 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 Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 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 (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible
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. 10% - After deductible Not Covered Hospital based clinic visits $45 Not Covered 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 $15 Not Covered PCP does not practice with PCMH model of care $35 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. $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 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. 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
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 20% - After deductible Hospital based clinic visits $50 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 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 Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% After deductible
Office Visits (other than Preventive Care Services). See Prevention and Early Detection Services for coverage of annual preventive officevisits.) Allergy injections - Applies to injection only, including administration. 0% 20% - After deductible Hospital based clinic visits $25 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 Retail clinics $15 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. $25 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $15 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - After deductible
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% 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 Transplants Organ transplant services 0% - After deductible 20% - After deductible
