Common use of Observation Services Clause in Contracts

Observation Services. In a hospital or other health care facility 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $50 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. $30 Not Covered Retail clinics $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. $50 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $50 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 20 Not Covered Retail clinics $30 20 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. $50 30 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 20 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility 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 0% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 0% - After deductible Not Covered Hospital based clinic visits $50 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 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 Not Covered Retail clinics $30 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. $50 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 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. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $50 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 Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $40 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. Standard $30 Not Covered Enhanced $15 Not Covered Retail clinics $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. $50 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 15 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible $40 Not Covered

Observation Services. In a hospital or other health care facility 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $50 40 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. $30 25 Not Covered Retail clinics $30 25 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. $50 40 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 25 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility 0% - After deductible Not Covered 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 Not Covered 20% - After deductible Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered 20% - After deductible Hospital based clinic visits $50 Not Covered 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 PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 Not Covered 25 20% - After deductible Retail clinics $30 Not Covered 25 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 Not Covered 40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 Not Covered 25 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible Not Covered 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered 40% After deductible Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered20% - After deductible

Observation Services. In a hospital or other health care facility 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 0% - After deductible Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 0% - After deductible Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 0% - After deductible Not Covered Hospital based clinic visits $50 0% - 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. $30 0% - After deductible Not Covered Retail clinics $30 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. $50 0% - After deductible Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 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. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered

Observation Services. In a hospital or other health care facility Standard 0% - After deductible Not Covered Enhanced 0% 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 Not Covered Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 Not Covered Hospital based clinic visits $50 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 Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 Not Covered Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 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. Standard $30 35 Not Covered Enhanced $20 Not Covered Retail clinics $30 35 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. $50 45 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 20 Not Covered Organ Transplants Organ transplant services 0% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible $45 Not Covered