Health & Security Plan > SPD > Physical Examinations – 90%

Summary Plan Description

Physical Examinations—90%

This Benefit Is For Children Through Age 25

Benefits are provided for preventive health services when performed by a physician. These services are not subject to the annual deductible but are subject to the office visit copayment(s) and annual coinsurance. All services are subject to the Preventive Health Benefit Schedule.

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

Preventive Health Benefit Schedule
Well Baby and Child Care
Well Baby Visits Total of 9 visits: At birth, 1 month, 2 months, 4 months, 6 months, 8-10 months,12-15 months,18 months, and 2 years.
Well Child Visits 3 visits between ages 3 and 6; then every 2 years between ages 7 and 18.
Ophthalmic Antibiotics At birth.
Haemophilus Influenzae Type B Vaccine (Hib) This four-dose series is given at 2 months, 4 months, 6 months, and 12-15 months.
Rotavirus Vaccine (RV) If RotaTeq is used, this three-dose series is given at 2 months, 4 months and 6 months. If Rotarix is used, only 2 doses are needed: at 2 months and 4 months.
Diphtheria, Tetanus, Pertussis Vaccine (DtaP) At 2 months, 4 months, 6 months, 12 months and once between ages 4 and 6.
Influenza Vaccine Annually beginning at 6 months, at physician's discretion.
Measles, Mumps, Rubella Vaccine (MMR) This two-dose series is given between 12 and 15 months and once between ages 4 and 6.
Inactivated Poliovirus Vaccine (IPV) Given at 2 months, 4 months, 6-18 months, and a booster between ages 4 and 6.
Tetanus-Diphtheria (Td) Booster or Tetanus Diphtheria-Pertussis (Tdap) Booster A dose of Td is given once between ages 14 and 16 and once every 10 years after age 18.

A dose of Tdap is recommended for adolescents ages 11 to 18 years who have not yet gotten a booster dose of Td.
Hepatitis A Vaccine (HepA) This two-dose series is given at least 6 months apart, between ages 12 and 23 months.
Hepatitis B Vaccine (HepB) A series of 3 shots between birth and 18 months.

The series can be obtained through age 18 if not previously completed.
Varicella Vaccine (Chickenpox) A two-dose series is given at 12 to 15 months and the second dose between 4 and 6 years of age (the second dose may be given earlier if at least 3 months after the first dose). Over the age of 13 years, a two-dose series is recommended 4 to 8 weeks apart.
Meningococcal Vaccine (MCV4) A single dose is recommended for children 11 through 18 years of age. It is normally given at ages 11 to 12 years.
Hemoglobin and Hematocrit Blood Test Once before age 2 years; then, between 24 months and 4 years, between 7 and 12 years, and between 13 and 18 years.
Urinalysis Recommended between ages 2 and 18 during well child visit.
Tuberculosis Test Once between ages 2 and 6 years.
Vision Test (not for eye prescriptions) Once between ages 7 and 12 years.
Hearing Test At birth and once between ages 2 and 6 years.
Eye Exam (test for amblyopia and strabismus) Once between ages 2 and 6 years.
Phenylalanine, Thyroxine, Thyroid-Stimulating Hormone Within the first 3 to 6 days of life.
Pneumococcal Conjugate Vaccine (PCV) Series of 4 doses, 1 dose at each of these ages: 2 months, 4 months, 6 months, and 12-15 months.
Additional screening tests conducted for patients who are considered "at risk" are not part of the basic preventive benefit but may be covered under the normal plan benefit subject to the annual deductible and coinsurance. If you have a condition that requires yearly check-ups, the check-up will be covered, subject to the annual deductible, copayment(s) and coinsurance.