Summary Plan Description

Preventive Health Services

100% Network and 80% Non-Network

Benefits are provided for preventive health services including periodic health and cancer screenings, well-child care, and certain vaccines and immunizations. To view a complete list of Affordable Care Act recommended preventive services for adult men, adult women and children, please refer to Services provided by network providers are not subject to the annual deductible, coinsurance or office visit copayment. Services provided by a non-network provider are subject to the annual deductible and office visit copayment and are subject to the maximum allowable fee as determined by the plan. Preventive health services for Medicare-eligible retirees are processed at the network level.