Preventive Care – 90%

Benefits are provided for screening procedures, x-rays, laboratory services, and routine immunizations performed by a physician based on the following schedule. If expenses exceed the schedule below, this plan will not pay the additional costs. Routine examinations are not covered, except for routine examinations for children as described under Preventive Care For Children.

Colorectal Cancer Screening

Benefits are provided for the following screening tests for men and women age 50 and older. There is no age limit for a colonoscopy:

• Fecal Occult Blood Test – Once each calendar year.
• Flexible Sigmoidoscopy – Once every four calendar years.
• Colonoscopy – Once every two calendar years if at high risk for cancer of the colon.
• Barium Enema – Physician can substitute for sigmoidoscopy or colonoscopy.

Prostate Cancer Screening

Benefits are provided for the following screening tests for men age 50 and older:

• Digital Rectal Examination – Once each calendar year.
• Prostate Specific Antigen (PSA) Test – Once each calendar year.

Mammogram Screening

Benefits are provided for the following screening tests:

• One baseline mammogram and its interpretation (women age 35-39).
• One mammogram and its interpretation each calendar year (women age 40 and older).

Routine mammograms obtained more frequently than this schedule are not covered unless an individual is designated high risk for breast cancer. An individual is considered at high risk for breast cancer if one 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.

Pap Smear

Benefits are provided for the following screening tests for women of all ages:

• Pap Smear – Once each calendar year.

Pap smears obtained more frequently than once each calendar year are not covered unless an individual is designated high risk.

Routine Immunizations For Adults

Benefits are provided for the following routine immunizations for the retiree and spouse:

• Influenza.
• Pneumococcal.
• Hepatitis B.

Visa or travel immunizations are not covered. Immunizations used to treat an illness, injury or direct exposure are covered as a medical benefit.

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 preferred or non-preferred physician bills an office visit. This $10 office visit copayment is in addition to the $10 office visit copayment for an office visit billed by a nonpreferred provider, and these office visit copayments do not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

• $400 maximum benefit during the first year of life (0 months through 11 months).
• $300 maximum benefit during the second year of life (12 months through 23 months).
• $200 annual 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 preventative care benefit for children after they attain age 19. Visa or travel immunizations are not covered. Immunizations used to treat an illness, injury or direct exposure are covered as a medical benefit.