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Preventive Care

If you are a member or an eligible family member of the active Medical Plan, your coverage provides an annual preventive care benefit:

  • $0 copay for yearly well visits with your primary care physician
  • $0 copay for annual well-woman visits with your gynecologist
  • certain health screenings and immunizations at no cost to you (These covered services are listed in the Preventive Schedule; see Booklets & Publications at right.)

Who's Eligible

You must

  • be an active member or eligible family member covered by the Medical Plan* (includes active, disabled, and continuation members and those members with transitional participation coverage); and
  • go to the doctor without signs or symptoms of illness for the annual exams, tests, and immunizations specified by the plan for your age and gender.

*Those enrolled in Triple-S, GeoBlue, or the Medicare Supplement Plan also have preventive care benefits under their plans, but coverage details may differ. Consult your plan’s provisions for details.

Preventive Care Coverage
Eligible Member Services Provider
Adults and children ages 3 and older Annual general wellness exam and specified screenings, immunizations, and blood tests Primary care provider
Females Annual well-woman exam and specified screenings, immunizations, and blood tests; contraceptives; breastfeeding counseling, support, and supplies; HIV counseling and screening; and more Gynecologist or nurse practitioner
Babies up to 30 months of age Specified well-baby visits and specified immunizations Pediatrician
Internationally adopted children through age 18 Additional specified screenings and immunizations Primary care provider

Preventive Care Coverage

Preparing for Your Well Visit

Make the most of your well visit. Before you go, do the following:

  • Review the Preventive Schedule (see Booklets & Publications above at right) to see which screenings and immunizations you qualify for based on your age and gender.
  • Print out your Personal Health Record (PHR) from to share with your doctor.
  • Make a list of any questions you have and bring them with you to your appointment.

At Your Checkup

Make sure you and your doctor cover these important items during your checkup:

  • Review your family history.
  • Discuss any changes in your health, if applicable.
  • Review the schedule of recommended screenings and immunizations. (The plan pays for specified preventive and screening services received from a primary care physician, pediatrician, or gynecologist, unless the service requires a specialist, such as a radiologist in the case of a mammogram, for example.)
  • Record your height and weight.
  • Perform a physical exam.
  • Discuss your test results. (If your doctor did not order tests before your visit, he or she should write orders for them at the end of the visit.)
  • Take the opportunity to ask any questions.

If the Doctor Diagnoses a Condition

Your well visit is covered under the preventive care benefit even if your doctor diagnoses a health condition during your exam. For any subsequent care related to that health condition or for tests that are not listed on the Preventive Health Schedule, you must pay your office visit copay, deductible, and 20 percent copayments.

If you think a preventive claim was not paid properly, please call Highmark at 888-835-2959. If you need more assistance, call the Board of Pensions at 800-773-7752 (800-PRESPLAN) and speak with a service representative.

Preventive Care Costs

Preventive care service Plan pays You pay
Annual well visit with a network providerPlan pays 100 percent for the visit$0
Annual well visit with an out-of-network providerPPO: Plan pays 50 percent of the plan allowance for the visit
EPO: Not covered
PPO: You pay the balance
EPO: You pay 100 percent
Scheduled preventive care screenings, tests, and immunizationsPlan pays 100 percent of plan allowanceYou pay $0

Confirming Network Participation

To confirm that your provider participates in the Highmark Blue Cross Blue Shield PPO or EPO network

  • visit the Find a Doctor section of Highmark’s website;
  • call Highmark at 888-835-2959; or
  • contact your provider's office.