Adult well visits

Well visits may be a key part of preventive care. They can reassure you that you are as healthy as you feel or prompt you to ask questions about your health. Evidence-supported services, based on the U.S. Preventive Services Task Force (USPSTF) A and B recommendations, are included as part of an adult well visit under the State Health Plan. After talking with your doctor during a visit, the doctor can decide which services you need from the approved USPSTF recommendations and build a personal care plan for you.

Standard Plan members

How the benefit works

Adult well visits are subject to copayments, deductibles and coinsurance in covered years. If you have not met your deductible, you will pay the $14 copayment plus the remaining allowed amount for the visit. If you have met your deductible, you will pay the $14 copayment plus your 20 percent coinsurance for the visit.

In a non-covered year, you can take advantage of the State Health Plan’s negotiated rate for an adult well visit. Eligible network providers have agreed to accept this rate as their total fee for an adult well visit. However, the amount you pay in a non-covered year does not apply toward your deductible or coinsurance maximum. Also, the negotiated rate applies to only one well visit each year.

Who is eligible?

The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the Standard Plan. Adult members can take advantage of this benefit at a network provider specializing in general practice, family practice, pediatrics, internal medicine, gerontology, and obstetrics and gynecology.

Eligible female members may use their well visit at their gynecologist or their primary care physician, but not both. If a woman visits both doctors in the same year, only the first routine office visit received will be covered. Women ages 18-65 can receive a Pap test each calendar year at no member cost through PEBA Perks.

Savings Plan members

Savings Plan members are eligible for one well visit each year at no member cost. The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the Savings Plan. Adult members can take advantage of this benefit at a network provider specializing in general practice, family practice, pediatrics, internal medicine, gerontology, and obstetrics and gynecology.

Services not included as part of an adult well visit

Services not included as part of the adult well visit are those without an A or B recommendation by the USPSTF. Find these recommendations at www.USPreventiveServicesTaskForce.org. Other services, including a complete blood count (CBC), EKG, PSA test and basic metabolic panel, if ordered by your physician to treat a specific condition, may still be covered. These services are subject to copayments, deductibles and coinsurance, as well as normal Plan provisions. Follow-up visits and services as a result of your well visit are also subject to normal Plan provisions.