Wellness and Preventive Services Benefits
The Indemnity Plan's wellness and preventive care benefits include routine physical and screening procedures, immunizations and North Carolina wellness benefits such as one-on-one health coaching about lifestyle issues, an interactive Web site and educational resources.
For example, a member needs both a physical and a mammogram during a Plan year (July 1 to June 30). If the member has the physical in July and the cost is $150, then the member has met the maximum wellness benefit for the year. If instead, the cost of the physical is $100, then the member can apply the remaining $50 toward the mammogram.
Any charges incurred more than the $150 wellness benefit maximum are subject to deductible and coinsurance requirements, as well as the $25 professional services copayment.
top
The $150 wellness benefit may be used for the services listed below:
*Effective July 1, 2005 – Mammograms are allowed each year (365 days in between screenings) for members age 40 and older as part of the $150 wellness benefit maximum.
top
Examinations and laboratory tests screening for early detection of cervical cancer are allowed each year (365 days) for female members of any age and are part of the $150 wellness benefit maximum.
The Plan DOES NOT pay benefits for physical examinations, tests and reports performed as part of employment, insurance, legal, school, camp, travel, athletic or governmental requirements.
If the immunization is dispensed as a prescription drug, it will be considered a prescription benefit and subject to the appropriate prescription copayment. The full series of standard immunizations recommended by the federal Centers for Disease Control and Prevention (CDC) is covered 100 percent.
For Disease and Case Management Services, see the Disease Management Page.
top
Routine Physical and Screening Procedures
The Indemnity Plan provides a $150 wellness benefit per Plan year (July 1 - June 30). The Indemnity Plan will pay 100 percent of allowable charges up to the $150 maximum. The $150 wellness benefit is not subject to deductible and coinsurance. The member remains responsible for the $25 copayment for professional services.For example, a member needs both a physical and a mammogram during a Plan year (July 1 to June 30). If the member has the physical in July and the cost is $150, then the member has met the maximum wellness benefit for the year. If instead, the cost of the physical is $100, then the member can apply the remaining $50 toward the mammogram.
Any charges incurred more than the $150 wellness benefit maximum are subject to deductible and coinsurance requirements, as well as the $25 professional services copayment.
top
The $150 wellness benefit may be used for the services listed below:
- Routine physicals
- Pap smears
- Breast, colon, rectal and prostate exams
- Blood pressure checks
- Mammograms
- Electrocardiograms
- Hearing tests
- Routine blood and urine tests
- Occult blood tests
- Chest x-rays
- Thyroid studies
- Tuberculosis tests
- General health checkups that are medically necessary for the maintenance and improvement of an individual's health
- Unlimited well visits for children from birth up to one (1) year
- Three (3) well visits for children between the ages of one (1) and two (2)
- One (1) visit each year (365 days must pass between visits) for children between the ages of two (2) and seven (7)
- One (1) visit every three (3) years (1,095 days between visits) for individuals between seven (7) and thirty-nine (39) years of age
- One (1) visit every two (2) years (730 days between visits) between forty (40) and forty-nine (49) years of age
- One (1) visit every year (365 days between visits) for individuals fifty (50) years and older
*Effective July 1, 2005 – Mammograms are allowed each year (365 days in between screenings) for members age 40 and older as part of the $150 wellness benefit maximum.
top
Examinations and laboratory tests screening for early detection of cervical cancer are allowed each year (365 days) for female members of any age and are part of the $150 wellness benefit maximum.
The Plan DOES NOT pay benefits for physical examinations, tests and reports performed as part of employment, insurance, legal, school, camp, travel, athletic or governmental requirements.
Immunizations
The State Health Plan provides benefits for immunizations for the prevention of certain contagious diseases. These benefits are not subject to the Plan year deductible and coinsurance requirements are paid at 100 percent of the usual and customary rate (UCR). You are, however, responsible for the $25 professional services copayment if charged for an office visit.If the immunization is dispensed as a prescription drug, it will be considered a prescription benefit and subject to the appropriate prescription copayment. The full series of standard immunizations recommended by the federal Centers for Disease Control and Prevention (CDC) is covered 100 percent.
- Diptheria-Pertussis-Tetanus Toxoid (DPT)
- Polio
- Measles-Mumps-Rubella (MMR)
- Influenza
- Pneumococcal vaccine
- HiB
- Hepatitis B
- Chicken Pox
- Meningococcal vaccine
- HPV vaccine
North Carolina HealthSmart Healthy Living Services
For Wellness Services, see the Wellness Services Page.For Disease and Case Management Services, see the Disease Management Page.
top
