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Preventative Services and Wellness Benefits

Using your Preventive Care Benefit is easy: call your (in-network) healthcare provider and make an appointment for your annual checkup. Covered services are available at no cost to you, and you can apply the $500 Wellness Benefit to some services and tests that aren’t covered under the Preventive Care Benefit. To see what’s covered, you can go to the government healthcare website.

The Health Fund will apply the (free) preventive services first and any remaining Wellness Benefits (that do not constitute preventive services) will be applied toward the Health Fund’s $500 per person or $1500/per family annual Wellness Benefit. In other words, the Health Fund will make sure that the free preventative services to which you are entitled are not credited against the Wellness Program, thus helping you to maximize the benefits you have available such as:

  1. Annual Routine Physical Exam
  2. Annual Routine Pap Smear
  3. Annual Well Woman Exam
  4. Annual Mammogram (Screenings/Routine)
  5. Breast Cancer (BRCA) BreastCancer susceptibility gene test
  6. Dyslipidemia Screening – Cholesterol testing (lab work)
  7. Immunizations/Vaccinations
    • (Age 0-7) paid under medical, subject to annual deductible and coinsurance
    • (Age 7+) paid under wellness (up to $500 annual maximum benefit). Anything over the maximum limit will be considered under the medical plan
  8. Genetic Testing
  9. Routine Prostate Specific Antigen (PSA) test to detect prostate cancer
  10. Nutritional Counseling
  11. Newborn Screening (routine testing for newborns)
  12. Weight management – the Health Fund will cover the program fees only, i.e., Weight Watchers, Jenny Craig, and Lindora. (Note: the Health Fund will not share cost for dietary food supplies or supplements)

All eligible Wellness Care expenses are reimbursed at 100% of either the contracted rate or the allowed amount after Reasonable and Customary (R&C) limits have been applied.

Please note: If the Wellness Benefit maximum is exhausted, eligible Wellness Care expenses will be considered under the medical plan, subject to the annual deductible, medical necessity review, and plan cost-sharing requirements. (Please Note: The Wellness Benefit is not available under the Low Option Plan).

What If My Medical Provider Is Out-Of-Network?

The Plan covers a physical exam under the Preventive Services Benefit of the Regular PPO Plan; it does not cover out-of network services. There also is no Preventive Benefit coverage for Participants under the Low Option Plan. However, if a Participant elects to get an annual exam from an Out-of-Network provider, the Wellness benefit can be applied as follows:

  • If you go to an Out-of-Network provider, physical exam and other specific services (i.e. routine immunization) are covered under the Wellness Benefit.
  • The Wellness Benefit is limited to a maximum benefit of $500 per individual per year and $1,500 per family per year.
  • Once the Wellness Benefit maximum is exhausted, the covered expenses exceeding the Wellness Benefit maximum are considered under the medical portion of the Plan. For example, the eligible expense for a routine physical exam is $800.
    • The Plan will pay the first $500 of the eligible expense under the Wellness Benefit.
    • The remaining $300 will be considered under the medical plan subject to the calendar year deductible of $400 and cost sharing (coinsurance) of 60% Plan responsibility and 40% Participant responsibility.
    • If no deductible has been met, the Plan’s maximum payment is $500 and the patient’s responsibility is $300.
    • If the $400 deductible is met, the Plan’s maximum payment is $680 ($500 under the Wellness Benefit and $180 (60% of the remaining $300, see item 1.d.ii.) under the medical plan) and the patient’s responsibility is $120 (40% of the remaining $300).

In practical terms, if your healthcare provider is out-of-network, it works like this:

Out-of-Network cost sharing, yearly deductible of $400 not met
Wellness Care eligible expense $800
Plan pays Wellness maximum of $500 $500
Participant pays ($300 remaining eligible expense applied to the yearly deductible) $300
Out-of-Network cost sharing, yearly deductible of $400 met
Wellness Care eligible expense $800
Plan pays Wellness maximum of $500 plus $180 (60% of $300, remaining eligible expense) $680
Participant pays (40% of $300, remaining eligible expense) $120

As you can plainly see, it is greatly to your advantage to utilize in-network healthcare providers. Anthem Blue Cross negotiates rates with doctors and other healthcare providers to help save you money. If you use in-network providers, you are not responsible for the amount over the contracted rate of any eligible Wellness care expense, even if the provider bills a higher amount.

When you receive eligible Wellness care services from an out-of-network provider, “Reasonable and Customary” (R&C) limits are applied. This means that any amount above the R&C limit is not considered an eligible expense and you are responsible for paying that amount.

In-Network or Out-of-Network, the Health Plan provides excellent, high quality coverage, and yet, a substantial number of Participants don’t take advantage of these resources. In 2017 less than half of the eligible Participants used any of their Wellness Benefit, and less than ten percent used all of this benefit:

Category Results
Number of patients who used the Wellness benefit in 2017 11,656
Number of patients who used all of the Wellness benefit in 2017 1,925
Most common Wellness services utilized in 2017 Physical exam to include routine tests and/or immunizations, followed by genetic testing
Note: For network providers, immunizations and genetic testing are covered under Preventive Care

Any healthcare provider will tell you how important it is to you and your family to get an annual checkup, and as you can see, considerable resources are available. If you want to know whether or not something not on the list might be covered, just call the Participant Services Department at (818) 846-1015 or (800) 227-7863 (follow the menu prompts). PWGA representatives will be glad to answer your questions.

Make this your healthiest year ever. You have Preventive Services (in-network) and up to $500 ($1,500 per family) annually in Wellness Benefits available to you to help you reach your goals and improve your health.