Preventive Care – 90%

Participant and Spouse

Benefits are provided for a routine physical examination, screening x-rays and laboratory services, and routine immunizations performed by a physician with an annual maximum of $400 for the participant and $300 for the spouse. If expenses exceed the $400 or $300 annual maximum, this plan will not pay the additional costs.

Each individual is responsible for the first $10 of covered expenses when a physician bills an office visit. Each individual is also responsible for an additional $10 of covered expenses when a nonpreferred provider bills an office visit (for care received in Washington State only). This $10 or $20 office visit copayment does not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

Pap Smear

Benefits are provided for a Papanicolaou’s (PAP) smear to screen for disease once each calendar year. Pap smears obtained more frequently than once each calendar year are not covered, unless the patient is designated high risk.

Routine Mammograms

Mammograms to screen for disease are covered up to the benefit maximums below:

• One baseline mammogram and its interpretation between the ages of 35 and 39.
• One mammogram and its interpretation each calendar year after age 40.

Routine mammograms obtained more frequently than this schedule are not covered unless the patient is designated high risk for breast cancer. A patient is considered high risk for breast cancer if one or more of the following conditions apply:

• Personal history of breast cancer.
• Personal history of biopsy-proven benign breast disease.
• A mother, sister or daughter had breast cancer.
• Not having given birth prior to age 30.

Preventive Care For Children

Benefits are provided for a routine physical examination, screening x-rays and laboratory services and routine immunizations performed by a physician based on the following schedule and benefit maximums. If expenses exceed the scheduled amount, this plan will not pay the additional costs.

Each individual is responsible for the first $10 of covered expenses when a physician bills an office visit. Each individual is also responsible for an additional $10 of covered expenses when a nonpreferred provider bills an office visit (for care received in Washington State only). This $10 or $20 office visit copayment does not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

• $400 maximum benefit during the first year of life (0 months through11 months).
• $300 maximum benefit during the second year of life (12 through 23 months).
• $200 maximum benefit during the third year through the eighteenth year of life (24 months through 18 years).

This benefit is based on the child’s date of birth, not calendar year. There is no preventive care benefit for children after they attain age 19. Visa or travel immunizations are not covered for adults or children. Immunizations used to treat an illness, injury or direct exposure are covered as a medical benefit.