Covered Benefits: Eligible Preventive Care


	Plan's Copayment for In-Network Care	Plan's Copayment for Out-of-Network Care*
Eligible Preventive Care** Please Note: Preventive care services will be free 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 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 free and/or covered.
Fecal Occult Blood Test	Free One test per year	$60 coverage after deductible One test per year
Immunizations (routine adult and child) (includes immunizations related to travel)	Free	$60 coverage after deductible
Preventive Sigmoidoscopy/Colonoscopy	Free One baseline screening and one follow-up screening every five years	$60 coverage after deductible One baseline screening and one follow-up screening every five years
Routine Gynecological Exams and Pap Smears	Free One exam and Pap smear per year (includes related laboratory fees); check with your provider for age guidelines	$60 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	Free Age 40 and over: one exam per year based on age and gender	$60 coverage after deductible Age 40 and over: one exam per year based on age and gender
Routine Physical Exams	Free One exam annually	$60 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)	Free	$60 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 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. JPMorgan Chase does not make this determination. For a list of preventive services go to your health care company's website accessible via My Health > My Medical Plan Website.