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 www.healthcare.gov/preventive-care-benefits. 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.