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You do not have to meet your medical deductible before the plan pays for services covered under the preventive care benefit.
- You pay nothing for preventive services when you see a network provider.
- If you see an out-of-network provider, you pay 50 percent of the allowed amount and may be balance billed.
- If you do not have access to a network provider for preventive services, the plan may pay 100 percent of billed charges. See page 15 of your network's certificate of coverage for how to request a network consent.
For the lists of services covered as preventive for adults, women, and children, visit Healthcare.gov or call UMP at 1-888-849-3681 (TRS: 711). Note that recommendations added during the calendar year may not be covered as preventive until later years.
Alert: This benefit covers only services that meet the criteria below. If you receive services during a preventive care visit that do not meet these requirements, or your provider bills your visit as medical treatment instead of a preventive service, the services will not be covered as preventive care. Instead, when medically necessary, the services are covered under the standard rate.
- Preventive visits such as well-baby care and annual physical exams.
- Preventive vision acuity screening from birth through 18 years of age.
- Intensive behavioral counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors.
- Screening for hepatitis B for non-pregnant adolescents and adults at high risk.
- Routine screenings for men and women (see list below for examples).
- Certain radiology and lab tests, such as screening mammograms.
- Screening procedures such as colonoscopy. See page 49 in your network's certificate of coverage for coverage of colonoscopy to diagnose or treat disease or illness.
- One-time screening by ultrasound for abdominal aortic aneurysm, for men ages 65-75 who have ever smoked.
- Immunizations as explained below.
- Hearing tests as part of a newborn screening.
- Fluoride for prevention of caries (dental decay) when prescribed by primary care provider to children age 6 months and older, when water is fluoride deficient.
- Certain screening tests performed during pregnancy. See page 59 in your network's certificate of coverage for more on prenatal care.
- Low to moderate dose of statin prescription drugs to adults ages 40 or over (statin medications that are designated as preventive on the UMP Preferred Drug List with a "PV" in the Tier column).
- Human Papillomavirus (HPV) testing for women ages 30 and over, once every three years.
- Chlamydia and gonorrhea testing in sexually active women age 24 years and younger, and for women age 25 and older who are at increased risk for infection.
- Education and counseling regarding contraception.
- Counseling and screening for HIV or interpersonal and domestic violence, and counseling for sexually transmitted infections.
- Low to moderate dose of statin medications to adults ages 40 and over (statin medications that are designated as preventive on the UMP Preferred Drug List with a "PV" in the Tier column).
For more services covered as preventive for women, read these sections in your network's certificate of coverage:
- Puget Sound High Value Network: Family planning services, Mammograms, and Obstetric and newborn care.
- UW Medicine Accountable Care Network: Family planning services, Mammograms, and Obstetric and newborn care.
Note: Prostate cancer screening (prostate-specific antigen [PSA] testing) is not covered under the preventive care benefit, but is covered as a medical benefit (subject to the medical deductible and coinsurance).
Alert: Follow-up visits or tests are not covered under the preventive care benefit. If the test or visit is normally covered by the plan and is medically necessary, the plan pays under the medical benefit.
The plan covers immunizations as included on the applicable immunization schedule (children, adolescents, adults) for U.S. residents by the Centers for Disease Control and Prevention (CDC).
Note that some covered immunizations are classified as "may be recommended" by the CDC depending on medical condition or lifestyle. For those immunizations to be covered as preventive, you must meet the criteria specified on the CDC schedule.
Immunizations covered under the preventive care benefit are not subject to the medical deductible. Covered immunizations given by the providers listed below are paid under the preventive care benefit. If you see an out-of-network provider for covered immunizations, you pay 50 percent of the allowed amount and may be balance billed.
Tip: Flu shots are covered as included on the applicable CDC immunization schedule.
Where can I get immunizations?
Immunizations covered under the preventive care benefit are covered at 100% when received from a:
- Network provider.
- Network vaccination pharmacy. To find one, visit the Find drugs page or call Washington State Rx Services at 1-888-361-1611 (TRS: 711).
- Public health department.
The plan does not cover immunizations for travel or employment, even when recommended by the CDC or required by travel regulations.