Preventive Services

Benefits are payable at 100% of the charges without application of the HIRSP deductible amounts for the following preventive screening services. This paragraph 28. does not apply to the following services when performed for diagnostic purposes to treat an illness or injury.

  1. Immunizations including, but not limited to, the following: diphtheria; pertussis; tetanus; polio; measles; mumps; rubella; hemophilus influenza B; hepatitis B; and varicella.
    Immunizations for travel purposes are not covered.
  2. One routine medical exam, excluding routine eye exams and routine hearing exams, per member per calendar year. Additional routine medical exams are not covered under this policy.
  3. Appropriate routine diagnostic laboratory services performed once per calendar year per member. Examples include complete blood count, total blood cholesterol test, thyroid function test, HIV antibody test, urinalysis, pap test, bone density testing, and prostate cancer screening.
  4. One routine examination by low-dose mammography of a female member per calendar year. Benefits are payable for one breast MRI in lieu of one routine examination by lowdose mammography if you receive the Plan Administrator’s prior approval. If you do not receive the Plan Administrator’s prior approval, benefits are not payable under this paragraph d. and will be payable subject to applicable deductible and coinsurance provisions. Mammograms must be performed by or under the direction of a physician or licensed nurse practitioner.
  5. Blood lead tests for members age five and under.
  6. Alcohol misuse and depression screening. 
  7. Colorectal cancer screening in accordance with the most current guidelines of the United States Preventive Services Task Force, including fecal occult blood testing, one routine sigmoidoscopy or colonoscopy every five years. Any additional routine sigmoidoscopies or colonoscopies performed within that five year period shall be payable subject to applicable deductible and coinsurance provisions.
  8. Nutritional counseling for a member who is diagnosed with morbid obesity or any other dietrelated chronic illness, other than an eating disorder such as bulimia or anorexia nervosa. Such counseling must be provided by a physician, a dietician or nutritionist licensed in the state where the counseling is provided to the member. This paragraph does not apply to such counseling when billed as educational services.

Preventive services other than those listed in a. through h. above will be payable subject to applicable deductible and coinsurance provisions.