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     Home → Welfare→ SPD → 5.14 PREVENTIVE HEALTH CARE


5.14 PREVENTIVE HEALTH CARE

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.



 

 
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