ALERT! This benefit covers only services that meet the criteria below. If you receive services during a preventive care visit that do not meet these requirements, they will not be covered as preventive care. Instead, when medically necessary, the services are subject to the deductible and are covered under the specific benefit the charges apply to (such as diagnostic tests, laboratory, or X-rays). If your provider bills for your visit as medical treatment instead of an annual physical exam or other preventive service, it may be covered under the medical benefit and subject to the deductible and coinsurance.
You don't have to meet your deductible* before the plan pays for services covered under the preventive care benefit. When you see a preferred provider for these services, you pay nothing. If you see an out-of-network provider, you pay 40% of the allowed amount and the provider may balance bill you. However, if you do not have access to a preferred provider for preventive services, the plan may pay 100% of billed charges. See how to request a network waiver.
For a list of services covered as preventive, see www.healthcare.gov/what-are-my-preventive-care-benefits/adults
. This site also features links to specific preventive services covered for women and children. Note that recommendations added during the calendar year may not be covered as preventive until later years.
TIP: You don't usually need to wait until a specific date between preventive care exams. For example, you could have a preventive exam near the end of one year, and again at the beginning of the next year; however, you would not qualify for another preventive exam until the following year. Some screening tests are limited; call 1-888-849-3681 with questions.
Examples of services covered under the preventive care benefit include:
- Preventive visits such as well-baby care and annual physical exams.
- Preventive vision acuity screening from birth through 18 years of age.
- Routine screenings for women (see below for examples).
- Certain radiology and lab tests such as screening mammograms.
- Screening procedures such as colonoscopy.
- Immunizations as specified under "Covered Immunizations".
- Hearing tests as part of a newborn screening.
- Certain screening tests performed during pregnancy; see more on prenatal care.
You may call Customer Service at 1-888-849-3681 to ask if a service is covered as preventive.
The following specific services for women are covered as preventive:
- Human Papillomavirus (HPV) testing for women ages 30 and over, once every three years.
- Education and counseling regarding contraception.
- Counseling and screening for HIV; counseling and screening for interpersonal and domestic violence; and counseling for sexually transmitted infections.
For additional services covered as preventive for women, see “Coverage of family planning services,” "Coverage of mammograms," and “Coverage of obstetric and newborn care.”
Prostate cancer screening (prostate-specific antigen [PSA] testing) is not covered under the preventive care benefit, but is covered as a medical benefit
(subject to the deductible* and coinsurance).
*For UMP Classic and UMP Plus, this is the medical deductible.
ALERT! Follow-up visits or tests are not covered under the preventive care benefit. If the test or visit is normally covered by the plan and is medically necessary, the plan pays under the medical benefit.