Page 31 - SIH 2022 Re-Enrollment Guide
P. 31
2022
SIH Benefits Re-Enrollment
PREVENTIVE CARE
SIH encourages you to be healthier by providing coverage for many preventive services. Many in-network
preventive services are already covered at 100% on our medical plan.
Take a look at this list of services covered at 100%, with no copayment, coinsurance, or deductible if coded as
a preventive care screening, not diagnostic or new patient. Please refer to your summary plan description for
more details.
Preventive Category Services Covered at 100% (In-Network Only)
Preventive/ Wellness Routine physical, well-child care, well-woman exam, routine prostate exam
Vaccinations Flu shots, HPV vaccine, measles, polio, meningitis, tetanus, shingles (ages 60 and over)
Routine Lab All routine lab work associated with annual preventive visit, blood pressure, diabetes, cholesterol, nicotine
Counseling Services Nutritional counseling, alcohol/tobacco use, aspirin counseling for stroke prevention
Disease Screenings Cervical cancer, colorectal cancer, depression, HIV, osteoporosis, diabetes
Pregnant Women Folic acid supplements*, screening for iron deiciency, hepatitis B, Rh incompatibility, breast feeding support
Well baby and well child exams up to age six, hearing and autism screenings, developmental assessments,
Children
behavioral assessments, oral health counseling
Cancer Preventive screenings, including skin cancer screenings, mammography for women
Well-woman exam, HPV screening, STD counseling, HIV counseling, contraceptive counseling, domestic violence
Women’s Preventive Services
counseling, counseling to support breastfeeding, and nursing mothers
Generic oral contraceptives* generic emergency contraceptives* diaphragms/Mirena* services for insertion/
Contraceptive Services
removal of IUD/cervical cap/implants, surgical sterilization procedures for women
* Covered under the prescription drug beneit
Please note: not all contraceptives are covered with no cost share; brand name contraceptives will continue to have the applicable copayment.
Please note if a visit or services are billed by a non-network provider, they will be covered subject to coinsurance.
31
SIH Benefits Re-Enrollment
PREVENTIVE CARE
SIH encourages you to be healthier by providing coverage for many preventive services. Many in-network
preventive services are already covered at 100% on our medical plan.
Take a look at this list of services covered at 100%, with no copayment, coinsurance, or deductible if coded as
a preventive care screening, not diagnostic or new patient. Please refer to your summary plan description for
more details.
Preventive Category Services Covered at 100% (In-Network Only)
Preventive/ Wellness Routine physical, well-child care, well-woman exam, routine prostate exam
Vaccinations Flu shots, HPV vaccine, measles, polio, meningitis, tetanus, shingles (ages 60 and over)
Routine Lab All routine lab work associated with annual preventive visit, blood pressure, diabetes, cholesterol, nicotine
Counseling Services Nutritional counseling, alcohol/tobacco use, aspirin counseling for stroke prevention
Disease Screenings Cervical cancer, colorectal cancer, depression, HIV, osteoporosis, diabetes
Pregnant Women Folic acid supplements*, screening for iron deiciency, hepatitis B, Rh incompatibility, breast feeding support
Well baby and well child exams up to age six, hearing and autism screenings, developmental assessments,
Children
behavioral assessments, oral health counseling
Cancer Preventive screenings, including skin cancer screenings, mammography for women
Well-woman exam, HPV screening, STD counseling, HIV counseling, contraceptive counseling, domestic violence
Women’s Preventive Services
counseling, counseling to support breastfeeding, and nursing mothers
Generic oral contraceptives* generic emergency contraceptives* diaphragms/Mirena* services for insertion/
Contraceptive Services
removal of IUD/cervical cap/implants, surgical sterilization procedures for women
* Covered under the prescription drug beneit
Please note: not all contraceptives are covered with no cost share; brand name contraceptives will continue to have the applicable copayment.
Please note if a visit or services are billed by a non-network provider, they will be covered subject to coinsurance.
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