Covered Services and Supplies

Medical Services and Supplies Office Visits

Office visits for services by a Physician are covered. Also covered are office visits for services by other health care professionals when you are referred by your Primary Care Physician.

Periodic Health Evaluations (including annual preventive physical examinations)
For preventive health purposes, a periodic health evaluation and diagnostic preventive procedures are
covered, based on recommendations published by the U.S. Preventive Services Task Force. In addition, a covered annual cervical cancer screening test includes a Pap test, a human papillomavirus (HPV) screening test that is approved by the federal Food and Drug Administration (FDA), and the option of any cervical cancer screening test approved by the FDA. Coverage includes annual preventive physical examinations as directed by Your Physician, or as otherwise medically indicated.

Vision and Hearing Examinations

Eye and ear examinations to determine the need for correction of vision and hearing are covered. Vision and hearing screenings, provided as part of a periodic health evaluation, are covered at no charge.

Hearing Aids
Standard hearing devices (analog or digital) inserted in or affixed to the outer ear to restore adequate
hearing to the Member and are determined to be Medically Necessary are covered. This includes repair and maintenance (but not replacement batteries).

Obstetrician and Gynecologist (OB/GYN) Self-Referral

If you are a female Member you may obtain OB/GYN Physician services without first contacting your Primary Care Physician.

If you need OB/GYN preventive care, are pregnant or have a gynecology ailment, you may go directly to an OB/GYN Specialist or a Physician who provides such services in your Physician Group.

If such services are not available in your Physician Group, you may go to one of the contracting
Physician Group’s referral Physicians who provides OB/GYN services. (Each contracting Physician
Group can identify its referral Physicians.)

The OB/GYN Physician will consult with the Member’s Primary Care Physician regarding the
Member’s condition, treatment and any need for Follow-Up Care.