Covered Benefits: Eligible Preventive Care


	Plan's Copayment/‌Coinsurance for In-Network Care	Plan's Coinsurance for Out-of-Network Care*
Eligible Preventive Care** Please Note: Preventive care services will be covered at 100% only if they are performed by an in-network provider and are 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 healthcare 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 free and/or covered.
Immunizations (routine adult and child; includes immunizations related to travel)	100% covered ($0 cost share)	50% coverage after deductible
Colon Cancer Screenings: • Fecal occult blood test (FOBT) or fecal immunochemical test (FIT): annually* • Flexible sigmoidoscopy: every 5 years Double-contrast barium enema (DCBE): every 5 years* • Colonoscopy: every 5 years • Computed tomographic colonography (CTC)/virtual colonoscopy: every 5 years*** - Requires precertification	100% covered ($0 cost share)	50% coverage after deductible
Routine Gynecological Exams and Cervical Cancer Screenings (Pap Smears)	100% covered ($0 cost share) 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% covered ($0 cost share) 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 Annual Physical Exams	100% covered ($0 cost share) One exam annually	50% coverage after deductible One exam annually
Routine Screenings Provided During Pregnancy (For example, gestational diabetes and bacteriuria screenings, as well as items such as certain breast pumps)	100% covered ($0 cost share)	50% coverage after deductible
Other Services
Durable Medical Equipment and Prosthetics (Includes certain**** glucose monitors, insulin pumps and related pump supplies)	20% after deductible	50% coverage after deductible
Lab	$20 Plan Option 1 $35 Plan Option 2	50% coverage after deductible
Prescription Drugs	Please see "The Prescription Drug Plan."
Standard Radiology	20% after 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 healthcare company determines which preventive care services performed by an in-network provider are free 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. JPMorganChase does not make this determination. Age and frequency limits may apply. Additionally, based on the medical finding resulting from preventive care, services may no longer be considered preventive and thus subject to member cost share. For a list of preventive services go to your healthcare company's website accessible via My Health > My Medical Plan Website.

*** Follow-up colonoscopy is covered as preventive at 100% in-network following a positive result.

**** Some glucose monitors, and insulin pumps are available under the prescription drug plan. For information on which insulin pumps are covered under the Medical and/or prescription drug plan, please contact the appropriate provider (Aetna/Cigna and/or CVS Caremark).