Covered Benefits: Eligible Preventive Care


	Plan's Coinsurance Percentage for In-Network Care	Plan's Coinsurance Percentage for Out-of-Network Care*
Eligible Preventive Care** Please Note: A medical service will only be covered at 100% if it is coded as preventive. Before receiving any service, you should check with your physician to be sure the procedure is considered, and will be submitted to your health care company, as preventive medical care rather than as a diagnostic service. Additional lab or other services performed during a preventive care visit that are not considered preventive in nature may not be covered at 100% with no deductible.
Fecal Occult Blood Test	100% before deductible One test per year	50% coverage after deductible One test per year
Immunizations (routine adult and child) (includes immunizations related to travel)	100% before deductible	50% coverage after deductible
Preventive Sigmoidoscopy/Colonoscopy	100% before deductible One baseline screening and one follow-up screening every five years	50% coverage after deductible One baseline screening and one follow-up screening every five years
Routine Gynecological Exams and Pap Smears	100% before deductible One exam and Pap smear per year (includes related laboratory fees); check with your provider for age guidelines	50% coverage after deductible One exam and Pap smear per year (includes related laboratory fees); check with your provider for age guidelines
Routine Mammography, Prostate Specific Antigen (PSA) Test, and Digital Rectal Exam	100% before deductible Age 40 and over: one exam per year based on age and gender	50% coverage after deductible Age 40 and over: one exam per year based on age and gender
Routine Physical Exams	100% before deductible**	50% coverage after deductible**
Routine Screenings Provided During Pregnancy (For example, gestational diabetes and bacteriuria screenings, as well as items such as certain breast pumps)	100% before deductible	50% coverage after deductible

* Covered out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount.

** Your health care company determines the preventive care services covered at 100% under the Plan based on guidelines and clinical recommendations for the general population developed by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and other nationally recognized sources. JPMorgan Chase does not make this determination. For a list of preventive services that are covered at 100%, go to your health care company's website accessible via My Health > My Medical Plan Website.