Preventive care is meant to help you stay as healthy as possible. Annual preventive visits, tests and screenings allow your primary care provider (PCP) to find, treat or prevent medical problems or diseases before they become major health concerns.
Talk with your PCP about which preventive care services you need and when you need them. Your PCP will consider things like family history, age, sex and current health status. Your PCP can also help coordinate any lab tests, screenings and vaccines you are due for.
See a list of covered preventive services from healthcare.gov.
Ask your clinic to verify your provider is in-network. With an in-network provider, preventive benefits are covered at $0. Non-preventive services may have some out-of-pocket costs (copays, deductibles, cost-sharing). Annual visits with your PCP, vaccinations (like the flu shot) and certain routine tests and screenings are examples of preventive care.
Note that not all screening tests are covered at no cost to you—it is only those that doctors and scientists have determined to be of the greatest value in keeping you healthy. Examples of tests that will lead to some cost-sharing are screening metabolic panels or a screening EKG.
If your plan uses a provider network, review your summary of benefits and coverage for network provider details.
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Preventive benefits |
Non-preventive services |
|---|---|
|
Annual preventive visit (1 per year, more visits for children and adolescents)
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If other health problems are present and addressed at your annual preventive office visit (e.g a sore throat), you may be billed for an office visit. Some costs may apply to visits that address chronic or pre-existing conditions, such as diabetes, heart problems, arthritis, depression, asthma or other chronic lung conditions, or mental health. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Mammogram (1 per year, starting at age 40): Screening x-rays of breast tissue to check for any signs of cancer or other abnormalities. Age and frequency recommendations vary, but benefits cover one screening mammogram annually starting at age 40. |
Testing if a breast lump is found or a follow-up test if screen is abnormal. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Age and frequency varies. May include a pap smear with HPV co-testing. |
Follow-up visits if pap smear is abnormal. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Colorectal (colon) cancer screening (starting at age 45): Five types of tests can be used to screen for colon cancer. Talk with your PCP about which is right for you. Visit cancer.gov to learn more about each screening type. Age and frequency recommendations vary, but benefits cover screenings starting at age 45. |
Additional colonoscopies if polyps or cancer are found. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Vaccinations (ages and frequency vary): Routine vaccines can prevent diseases such as HPV, chickenpox, shingles, tetanus, measles, mumps, rubella, polio and whooping cough. Doses and age-specific vaccines vary. |
Vaccines for travel outside the U.S. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Age may vary, covered once every year. |
Testing if you have high cholesterol. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Age and frequency varies. |
Medications to treat an infection. |
| Preventive benefits | Non-preventive services |
|---|---|
|
Adults and adolescents. |
Medications to treat an infection (e.g. chlamydia). |
Your insurance may cover more services than are recommended.
Talk to your doctor about which services you should receive.
Covered preventive services listed are for the 2023 benefit year and may change after 2023. Some labs, when provided as part of a preventive visit, are covered at 100%. To understand what labs are covered, see plan for details or call Customer Care at 866-514-4194.
Some health care terms are used the same way when they may, in fact, mean something different. For example:
Some health care terms mean the exact same thing. For example:
As your children grow, it’s important to keep them protected from serious diseases. Check with your doctor to ensure your child receives their childhood vaccines – including their flu vaccine - on time.
You and your children can receive these essential immunizations from your provider at your annual preventive care visit.
Health plan members, ages six and older, can also get vaccines at the pharmacy. Find a pharmacy near you.
If you receive preventive care marketing materials from sources other than your Health Plan, PCP or primary clinic, ask your PCP if you are due for the stated service or screening and how it’s covered by your health insurance.
To see your specific preventive care coverage details, review your member certificate and summary of benefits.
You can also call the Customer Care Center number listed on the back of your membership card to ask questions about your coverage.
Annual visits with your PCP, vaccinations (like the flu shot) and certain routine tests and screenings are examples of preventive care.
These preventive services, and more, are covered at no ($0) out-of-pocket costs to you when received by an in-network provider*:
Telehealth may be used for annual preventive visits or other appointments if no labs, physical exam, screenings or vaccines are needed. Talk with your PCP if you are interested in a telehealth appointment. If your plan uses a provider network, review your summary of benefits and coverage for network provider details.
Learn about expanded telehealth services.
Preventive care is meant to help you stay as healthy as possible. Annual preventive visits, tests and screenings allow your PCP to find, treat or prevent medical problems or diseases before they become major health concerns.
Talk with your PCP about which preventive care services you need and when you need them. Your PCP will consider things like family history, age, sex and current health status. Your PCP can also help coordinate any lab tests, screenings and vaccines you are due for.
See a list of covered preventive services from healthcare.gov.
Non-preventive care is any care in which symptoms are present, or when treatment of an illness or management of other medical conditions is needed. This may include care for some medical conditions when a cure may be possible.
These services will have out-of-pocket costs (copays, deductibles, cost-sharing):
Existing health concern or chronic medical condition services received at an annual preventive visit: For example, treating asthma, a rash or a sore throat during your annual preventive visit.
Diagnostic tests that result from screenings: For example, if your provider needs to see additional images after your screening mammogram, the follow-up mammogram is considered diagnostic and will include cost share.
Additional primary care visits: One annual preventive visit with your PCP is covered (more visits for children and adolescents are covered). Other visits during the same calendar year will not be covered as preventive. For example, if you have flu symptoms and need to see your PCP—that’s not a covered preventive visit.
Specialist visits and alternative therapies: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem are not covered as preventive care. Services such as chiropractic, massage, acupuncture, and other alternative health services are usually not covered as preventive care.
Preventive care is provided at visits that are usually with your primary care provider (PCP). Routine screenings, shots (vaccinations), and counseling to prevent illness, disease or other health problems are a few examples of preventive care.
Diagnostic care refers to services provided as a result of symptoms or problems you have, previously identified diagnoses or problems, or after the results of a preventive test or screening are reviewed. The follow-up care is diagnostic and not covered as preventive care.
Diagnostic and follow-up care may have out-of-pocket costs (copays, deductibles, cost-sharing).
Chronic care refers to services provided to help you manage chronic illnesses, such as diabetes, asthma, high blood pressure, or high cholesterol. This care is also not covered the same way as preventive care, and will usually have out-of-pocket costs like diagnostic care does.
If you and your provider discuss any of your chronic illnesses at your annual preventive visit, you may have out-of-pocket costs.