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Preventive Care Benefits |
SILVER BENEFIT |
BRONZE BENEFIT |
QHDHP BENEFIT |
OFFICE VISIT COPAY
BENEFIT |
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IN NETWORK |
OUT of NETWORK |
IN NETWORK |
OUT of NETWORK |
IN NETWORK |
OUT of NETWORK |
IN NETWORK |
OUT of NETWORK |
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Plan Pays |
Plan Pays |
Plan Pays |
Plan Pays |
Plan Pays |
Plan Pays |
Plan Pays |
Plan Pays |
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Note: Not Subject to Deductible.
Benefit equals 100% of charge up to specified limits |
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Annual
Physical Examination (age 5+) |
$400 Maximum Benefit |
No Benefit |
$400 Maximum Benefit |
No Benefit |
$400 Maximum Benefit |
No Benefit |
$400 Maximum Benefit |
No Benefit |
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Colonoscopy -
$2,000 Maximum Covered Charge |
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Age < 50 |
No Benefit |
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Age 50 + |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
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Hemocult - $32 per a test Maximum Covered
Charge |
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One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
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Immunizations |
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Children to
age 19 subject to Physician recommendation |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
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Adults - Age
19 + subject to Physician recommendation |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
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Mammography - $136 per mammogram
Maximum Covered Charge |
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Age < 30 |
No Benefit |
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Age 30-39 |
One baseline mammogram. |
No Benefit |
One baseline mammogram. |
No Benefit |
One baseline mammogram. |
No Benefit |
One baseline mammogram. |
No Benefit |
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Age 40-49 |
One every other Plan Year. |
No Benefit |
One every other Plan Year. |
No Benefit |
One every other Plan Year. |
No Benefit |
One every other Plan Year. |
No Benefit |
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Age 50 + |
One per Plan Year |
No Benefit |
One per Plan Year |
No Benefit |
One per Plan Year |
No Benefit |
One per Plan Year |
No Benefit |
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Pap Smear
Cytology One test per Plan Year. |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
100% |
No Benefit |
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PSA Blood Test - $144 per test Maximum Covered Charge |
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Age <50 |
No Benefit |
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Age 50+ |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
One test per Plan Year |
No Benefit |
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Well Child
Care – through age 4 |
80% |
50% |
80% |
50% |
80% |
50% |
100% after $30 Copay |
50% |
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