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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, they will not be covered as preventive care. Instead, when medically necessary, the services are subject to the medical deductible and are covered under the specific benefit the charges apply to (such as diagnostic tests, laboratory, or X-rays). If your provider bills for your visit as medical treatment instead of an annual physical exam or other preventive service, it will be covered under the medical benefit and subject to the deductible and coinsurance.
You don't 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.
- For non-network or out-of-network providers, you pay 50% of the allowed amount. Out-of-network providers may balance bill you.
- If you do not have access to a network provider for preventive services, the plan may pay 100% of billed charges. See how to request coverage of non-network or out-of-network services.
For a list of services covered as preventive, go to Healthcare.gov. This site also features links to specific preventive services covered for women and children. Recommendations added during the calendar year may not be covered as preventive until later years.
TIP: You don't usually need to wait until a specific date between preventive care exams. For example, you could have a preventive exam near the end of one year, and again at the beginning of the next year; however, you would not qualify for another preventive exam until the following year. Some screening tests are limited.
- 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 women (see list below for examples).
- Certain radiology and lab tests such as screening mammograms.
- Screening procedures such as colonoscopy; see "Coverage of diagnostic tests, laboratory, and x-rays" for coverage of colonoscopy performed 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 specified under "Covered Immunizations".
- Hearing tests as part of a newborn screening.
- Fluoride for prevention of caries (dental decay); prescribed by primary care provider to children age 6 months and older, when water is fluoride deficient; see details about coverage. See "Coverage of dental services" for coverage of fluoride varnish.
- Certain screening tests performed during pregnancy; see more on prenatal care.
- 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; counseling and screening for interpersonal and domestic violence; and counseling for sexually transmitted infections.
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.
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