Commercial Participants - Preventive Care Benefits-at-a-Glance
Commercial Actives and Non-Medicare Retirees
Adult Physical Exams
- One per Calendar Year
In-Network: $20 copayment
Out-of-Network: Not covered
Well-Woman Office Visits
In-Network: $20 copayment
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Well-Child Office Visits
- From birth up to 1st birthday: 7 visits
- Ages 1 through 4 years of age: 7 visits
- Ages 5 through 11 years of age: 7 visits
- Ages 12 up to 17 years of age: 6 visits
- Ages 18 to 19th birthday: 2 visits
In-Network: $0
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Adult Immunizations
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Certain Child Immunizations
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Cholesterol Testing
- One every 24 months up to age 35; after age 35 one every 12 months
In-Network: $15 copayment
Out-of-Network: Not covered
Colonoscopy
The American Medical Association (AMA) has issued the following guidelines for colorectal cancer screenings for all members age 45+:
- Colonoscopy: 1 every 10 years
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Fecal Occult Blood Test (Colon Cancer)
The American Medical Association (AMA) has issued the following guidelines for colorectal cancer screenings for all members age 45+:
- Fecal occult blood test: 1 every year
Out-of-Network: 20% after deductible plus any amount above the allowed amount
PSA Blood Test
- One test every 12 months for males with average risk starting at age 50; high risk start earlier
In-Network: $15 copayment
Out-of-Network: Not covered
Sigmoidoscopy—Diagnostic
The American Medical Association (AMA) has issued the following guidelines for colorectal cancer screenings for all members age 45+:
- Sigmoidoscopy: 1 every 5 years
In-Network: $15 copayment
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Sigmoidoscopy—Biopsy
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Pap Smear Lab Test
- Annual cervical cancer screening for females starting when sexually active
In-Network: $15 copayment
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Preventive Mammogram
- One baseline ages 35 – 39; annually starting at age 40, according to the recommendations of the American Cancer Society
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Bone Density Testing and Treatment
- Ages 52 through 64: one baseline
- Ages 65 and older: one every 24 months (if baseline before age 65 does not indicate osteoporosis)
In-Network: 20% after deductible
Out-of-Network: 20% after deductible plus any amount above the allowed amount
Newborn Exams
Newborn Exams
- Two in-hospital exams at birth following vaginal delivery
- Four in-hospital exams at birth following c-section delivery
In-Network: $0
Out-of-Network: 20% after deductible plus any amount above the allowed amount
For More Information
For more information on preventive care, please visit the SPD for Actives and Retirees in the Commercial Division section.
FAQs
As an Active Member, what is our hospital and medical coverage?
The Health and Benefit Trust Fund offers hospital and medical benefits to active eligible participants. Medical benefits include coverage for preventive care, doctor visits, hospital stays and other medical services. The Health and Benefit Trust Fund shares most of the cost of medical services when you visit in-network providers, meaning you pay less out-of-pocket for your health care. For more information, go to the Medical Benefits page.