Preventive care

Preventive care can help us stay well and detect conditions early, when they are easier to treat.

All three medical coverage options — PPO, EPO, and HDHP — provide an annual preventive care benefit for you and your enrolled family members.* There is no cost to you when using network providers for the following:

  • yearly well visits with your primary care physician
  • annual well-woman visits with your gynecologist 
  • wellness exams for children
  • health screenings and immunizations listed on the Preventive Schedule 
  • additional specified screenings and immunizations for internationally adopted children up to age 18 

For a service to be considered preventive, you must 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.

Preparing for your well visit

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

  • Confirm that your doctor is a network provider by
    • calling the Member Services number on the back of your medical ID card; 
    • using the provider search tool on your service provider’s website; or
    • contacting your doctor’s office.
  • Review the Preventive Schedule to see which screenings and immunizations you qualify for based on your age and gender.
  • Make a list of any questions you have and bring them with you to your appointment.

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 Schedule, you must pay the applicable copay, deductibles, and/or 20 percent coinsurance (previously referred to as copayments).

If you think a claim for a preventive service was processed incorrectly, call your service provider. If you need more assistance, call the Board of Pensions at 800-773-7752 (800-PRESPLAN).

Coverage of additional services

The Board follows the recommendations of the U.S. Preventive Services Task Force. If a provider conducts tests or services beyond those recommendations, they are considered to be beyond the scope of the preventive care benefit and subject to regular plan provisions (i.e., deductibles, copays, and/or coinsurance). For example, some providers perform routine electrocardiograms (EKGs) during preventive exams; coverage for this test would be subject to regular plan provisions.

Out-of-network reimbursement (PPO only)

If you’re enrolled in the PPO medical option and see an out-of-network provider for preventive care when a network provider is available, the plan pays 50 percent of the plan allowance for preventive office visits, with no deductible, and you pay the remaining 50 percent plus any charges above the allowed amounts. Blood work, screenings, and tests listed on the Preventive Schedule (for your age and gender) are covered at 100 percent.

To find network providers, call the number on the back of your medical ID card or visit your service provider’s website.

Note: The EPO and HDHP do not cover preventive care services received from out-of-network providers.

Preventive health recommendations for internationally adopted children

If you have medical coverage* through the Board of Pensions, you can take advantage of a benefit designed to meet the unique health needs of children adopted from other countries. This benefit is available for children through age 18 and includes the following:

  • Overseas medical exam to detect contagious diseases that could affect their eligibility to obtain a visa.
  • Exams and certain health screenings, such as hepatitis screenings, HIV ELISA, stool examination for ova and parasites, skin testing for tuberculosis, and G6PD deficiency screening, in the United States. Children adopted from other countries should have a thorough exam by a pediatrician within one to two weeks of their arrival. After initial screening, children may need to be retested for some diseases.
  • Other recommended screenings, including hearing, vision, and developmental screenings as well as a dental evaluation for children age 18 months and older.

See Guide to Your Healthcare Benefits for more information, including a detailed list of recommended health screenings for internationally adopted children.

*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.