Health & Security Plan > SPD > Preventive Benefit Health Schedule

Summary Plan Description

Preventive Health Care Benefits Table

For All Adults (Ages 19 and Older)
Type of Service Frequency
Health Evaluation Every 3 years for children ages 19-25; annually for participants, spouses and domestic partners.
Blood Glucose Test Every 3 years for children ages 19-25; annually for participants, spouses and domestic partners.
Total Lipid Profile Test Every 3 years for children ages 19-25; annually for participants, spouses and domestic partners.
Fecal Occult Blood Test Annually beginning at age 50.
General Health and Basic Metabolic Panel Every 3 years for children ages 19-25; annually for participants, spouses and domestic partners.
Digital Rectal Examination Annually beginning at age 40.
Colorectal Cancer Screening Beginning at age 50, annual fecal occult blood test plus one of the following screening options:
  • Flexible sigmoidoscopy every 5 years; or
  • Colonoscopy every 5 years; or
  • Double contrast barium enema every 5 years.
Influenza Vaccine Annually.
For Women
Gynecological Examination Annually beginning at age 18 or earlier if sexually active.
Mammography Baseline mammogram test once between ages 35 and 40. Annually beginning at age 40.
Pap Smear Test Annually beginning at age 18 or earlier if sexually active.
Chlamydia Screening Annually beginning at age 18 or earlier if sexually active (usually done during a routine gynecological exam).
Clinical Breast Examination Annually beginning at age 18.
Human Papillomavirus Vaccine (HPV) This three-dose series is given over a six-month period, for young adolescents and women between ages 9 and 26.
Thyroid Test (TSH) Every 5 years beginning at age 35.
Osteoporosis Screening (bone mass measurement test) Once every 2 years for post menopausal women.
For Men
Clinical Testicular Examination Annually and recommended during well child visit and health examination.
Prostate-Specific Antigen (PSA) Test Annually beginning at age 50 or earlier if determined to be at high risk.
Abdominal Aortic Aneurysm Screening Ultrasound Once in a lifetime for men ages 65 through 75 who smoke or previously smoked.
Osteoporosis Screening (bone mass measurement test) Once every 2 years for men age 70 and older.
Additional Tests and Immunizations for Men and Women
Tetanus Diphtheria (Td) or Tetanus, Diphtheria and Acellular Pertussis (Tdap) Booster Shot Every 10 years after age 18.
Pneumococcal Polysaccharide Vaccine (PPSV) Once on or after reaching age 65. Starting at younger age for certain risk factors.
Shingles Vaccine (Herpes Zoster) A single dose for adults age 60 and older.
Hearing Test Once on or after reaching age 65.
Visual Acuity/Glaucoma Tests Every 3 years beginning at age 65.
Screening Urinalysis Annually.
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 though 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.