The calendar year deductible does not apply to the following preventive care services. Covered Expenses for preventive health care are payable at 100%.
Routine Physical Examination
Benefits are payable for routine physical examinations. The maximum benefit payable per Participant per calendar year is $300.
Covered Expenses include:
| Benefits paid at 100% of UCR, not subject to the deductible | ||
|---|---|---|
| What | For Whom | How Often |
| Mammogram, including physician’s office visit | Women ages 35 to 39 Women ages 40 to 49 Women ages 50 and over |
One Baseline Screening Every Two Years Annually |
| Pap Smear, including physician’s office visit | Women age 18 and over | Annually |
| Benefits paid at 100% of UCR, not subject to the deductible, with a $300 annual maximum | ||
|---|---|---|
| What | For Whom | How Often |
| Routine Physical Exam performed by a Physician. Diagnostic x-rays and laboratory tests | Age 13 and over | Annually |
| Well Child Care | Age 12 and Under | As needed |
| Digital Rectal Exam | Over age 40 | Annually |
| Prostate Examination for men at risk for prostate cancer | Men | Annually |
| Fecal Occult Blood Test | Over age 50 | Annually |
| Benefits paid at 70% of UCR, not subject to the deductible | ||
|---|---|---|
| What | For Whom | How Often |
| Flexible Sigmoidoscopy | Over age 50 | Every Two Years |
| Total Colon Examination by Double Contrast Barium Enema | Every Five Years | |
| Total Colon Examination by Colonoscopy | Every Ten Years | |
A routine physical examination is a medical exam performed by a Physician when the Participant has no signs of Illness or Injury. The exam includes diagnostic x-rays and laboratory tests, a review of the Participant’s medical history, and discussion of the results of the examination. For the purposes of this benefit, a routine physical examination does not include special testing, such as an electrocardiogram performed while running on a treadmill.
The routine physical examination benefit is available to Dependents age 13 and older.
Well Child Care
The well child care benefit is available to Dependent children age 12 and under. The maximum benefit payable per calendar year is $300. Routine well child care in excess of $300 per year is payable on the same basis as Medically Necessary services.
Immunizations
Benefits are payable for immunizations dispensed by a Health Care Provider. The maximum immunization benefit payable per Participant per calendar year is $500. The Plan does not cover immunizations related to foreign travel.