With few exceptions, group health plans offer 100% coverage for preventive care services, which include routine physicals, well-baby exams, well-woman exams and immunizations. There is generally a benefit limitation, but the dollar amount is based on average costs and should cover routine services.
If you see a physician for preventive services, and the office visit is filed with a medical diagnosis, the visit may no longer be considered preventive and the claim could process differently.
Example: A woman has a mammogram. If the mammogram is filed as routine, then coverage can be 100%. But, if the mammogram is filed with a medical diagnosis, the charges for the mammogram may be subject to deductible and coinsurance.
Big Difference!
Routine exams should be exactly that. If you are sick or have a specific medical condition you are seeking medical advise for, the medical services received are no longer considered preventive.
Hopefully this information will be helpful to you in maximizing the usage of your preventive care benefits.