Examples of Preventive Care Covered Services are routine or periodic exams, including school enrollment physical exams. (Physical exams and immunizations required for travel, enrollment in any insurance program, as a condition of employment, for licensing, sports programs or for other purposes, are not Covered Services.)

Examinations include, but are not limited to:

  • Well-baby and well-child care, including child health supervision services, based on American Academy of Pediatric Guidelines. (Child wellness benefits extend to the limiting age, typically 19; if still an eligible dependent, wellness is covered under the adult wellness guidelines.)
  • Child health supervision services includes, but is not limited to, a review of a child's physical and emotional status performed by a physician, by a health care professional under the supervision of a physician, in accordance with the recommendations of the American Academy of Pediatrics and includes a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests.
  • Adult routine physical examinations (please see exclusions above).
  • Pelvic examinations.

Covered Services:

  • Routine EKG, chest X-ray, laboratory tests such as complete blood count, comprehensive metabolic panel, urinalysis.
  • Annual dilated eye examination for diabetic retinopathy.
  • Immunizations (including those required for school), following the current Childhood and Adolescent Immunization Schedule as approved by the Advisory Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). For adults, thepPlan follows the Adult Immunization Schedule by age and medical condition as approved by the Advisory Committee on Immunization Practice (ACIP) and accepted by the American College of Gynecologists (ACOG) and the American Academy of Family Physicians.

Immunizations include, but are not limited to:

(Please see exclusions above.)

  • Hepatitis A vaccine series
  • Hepatitis B vaccine series
  • Haemophilus influenza type b vaccine (Hib)
  • Influenza virus (Flu) vaccine
  • Rabies vaccine
  • Tetanus, Diphtheria and Pertussis (TDAP) vaccine
  • Measles, Mumps and Rubella (MMR) vaccine
  • Poliovirus  (IPV) vaccine
  • Human Papillomavirus (HPV)

Screening examinations:

  • Routine vision screening for disease or abnormalities, including but not limited to diseases such as glaucoma, strabismus, amblyopia, cataracts;
  • Routine hearing screening;
  • Routine screening mammograms;
  • Routine cytological and chlamydia screening (including pap test).

Screening examinations, continued:

  • Routine bone density testing for women;
  • Routine prostrate specific antigen testing;
  • Routine colorectal cancer examination and related laboratory tests.

Diabetes Self-Management Training:

Diabetes Self-Management Training is covered for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition when:

  • Medically necessary;
  • Ordered in writing by a physician; and
  • Provided by a Health Care Professional who is certified by the American Diabetes Association or is a Certified Diabetic Educator (CDE). A diabetes education session must be provided by a Health Care Professional in an outpatient facility or in a physician's office.

For the purposes of this provision: A "Health Care Professional" means the physician ordering the training or a provider who has obtained certification in diabetes education by the American Diabetes Association or a Certified Diabetic Educator.

Preventive Care benefits may vary based on the age, sex, and personal history of the individual, and as determined appropriate by the administrator's clinical coverage guidelines and as considered usual customary by the medical community. Screenings and other services are generally covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service. Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit.

Premium Plan Preventive Care Services as described above will be covered at 100% after in-network $0 co-payment. They will not be subject to the annual deductible or co-insurance.

Premium Plan Preventive Care Services as described above will be covered at 70% after out-of-network $15 co-payment subject to a maximum of $350 per plan year. Expenses will not be subject to the annual deductible.

Basic Plan Preventive Care Services as described above will be covered at 100% after in-network $0 co-payment. They will not be subject to the annual deductible.

Basic Plan Preventive Care Services as described above will be covered at 50% after out-of-network $20 co-payment subject to a maximum of $350 per plan year. Expenses are not subject to the annual deductible.