Preventative Care Services. The Plan covers Primary Care and Specialist services for Preventative Care and periodic health exams. Although Preventative Care is covered at no charge, an office visit Copay may apply for other Covered Services provided during Your visit. The Plan also covers all Essential Health Benefits, including those listed in this Contract. There is no cost sharing for Essential Health Benefit Preventative Care Services. Coverage of Benefits is available for all USPSTF A and B recommendations, HRSA for women and HRSA and ACIP for infants, children and adolescents.
Preventative Care Services. 1. Dental: Claims for covered dependents under age eighteen (18) for oral examination and fluoride treatment are reimbursed at one-hundred percent (100%) and are not subject to the Benefit Year dollar amount, if these services are not covered under the employee's health insurance plan.
2. Vision: Claims for covered dependents under age eighteen (18) for routine vision examination reimbursed at one-hundred percent (100%) and are not subject to the Benefit Year dollar amount, if these services are not covered under the employee's health insurance plan.
Preventative Care Services. Annual Routine Pap Smear • Mammogram • PSA and DRE • Routine Physical Checkups (Adults) • Routine Pediatric Checkups, Well Baby Care & Pre-school exams • Immunizations • Routine Bone Density Test • Smoking Cessation Services • Healthy Diet Counseling The listed preventative care services including related office visits and physician fees, will be covered at 100% of the eligible charge. The annual deductible will not apply to the preventative care services. Covered employees and dependents must use a Participating Provider to receive the maximum benefit coverage. For employees in the HMO, the following will apply: • A $20.00 co-payment for office visits will be required. • The annual out-of-pocket expense limit is $1,500.00 per individual and a maximum of $3,000.00 per family. • A $100.00 co-payment for the emergency room will be required. The co-payment is waived if the patient is admitted from the emergency room. For employees in the HMO, effective February 1, 2018, the following will apply: • A $25.00 co-payment for office visits will be required. • A $25.00 per admission deductible for outpatient services will be required. Employees who are covered under either the PPO or HMO plan will receive prescription drug coverage according to the following schedule: Retail Card Based on a 30-day supply Co-payment Generic $ 9.00 Formulary $25.00 Non-Formulary $45.00 Specialty $100.00 Employees may obtain up to a 90-day supply of maintenance drugs. Employees are strongly encouraged to use mail order for maintenance drugs. Generic $18.00 Formulary $50.00 Non-Formulary $90.00 The formularies are determined by the pharmacy benefits manager and the mail order provider, and are not subject to notice of changes or approval of such changes by the District. The annual out-of-pocket expense limit for prescription drugs is $1,000.00 per individual, $2,000.00 for Employee + 1 and a maximum of $2,700.00 per family.
