- Routine Physicals – one per calendar year – includes all services billed with a “routine diagnosis”. Services are to be directed by PCP or referred Specialist. Must pay $30 copay, then pays 100% if in network, no deductible.
- Present coverage continues for PSA, Occult Blood Exam, GYN and Mammogram coverage.
Smoking Cessation Programs
- Services are to include In-Network Provider visits and Prescription drugs, to be paid under the drug card (Rx covered as currently-covers all prescribed drugs). Also includes only OTC patches or gum IF a prescription is written for them by a valid provider.
- Reimbursed: PCP co-pay then 100%, or standard benefits if referred to an in-network provider – for medical providers. Prescriptions for drugs are at a regular 3-tier level; however any OTC patches or gums prescribed would have a $25 co-pay per 34 day supply.
- Referrals are required if treatment is outside PCP.
- No out of network services are covered.
- No dollar maximum.
Routine Well Child Care
- Immunizations 0-18 years of age; and regular routine check-ups.
- Dollar Maximum: through Age 6 is still covered 100%, subject to office copay.
PSA and Occult Blood Exam-Males age 40 and older
- Same Coverage
Routine Gynecological Examinations
- Same Coverage
- One per calendar year covers office visit, pap smear, urinalysis, hematocrit or hemoglobin and hemoccult stool culture.
- Age 35-39 one baseline exam
- Age 40 + one exam every calendar year and reimbursed as 100%, no deductible if by PCP; 80% if in-network. Services must be rendered by the PCP or an In-Network provider.
- Covered 100% after $30 co-pay, no deductible. Adult immunizations not covered.