Benefits Table Outpatient Services Benefits
Copayment
How to Obtain Covered Services
Limitations & Exclusions
Pediatric/Well- Child Care including periodic office visits, diagnostic services, immunizations, and the testing and treatment of phenylketonuria (PKU).
$0 Copayment
Call to schedule an appointment with your child’s VHP Network PCP.
The age, health status, and medical needs of the child determine the frequency of these examinations.
Adult Periodic Health Examinations including immunizations, diagnostic services, Pap smears, Prostate Specific Antigen (PSA) tests, and all generally medically accepted cancer screening tests.
Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan. org $0 Copayment
Call to schedule an appointment with your VHP Network PCP. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan. org
Frequency is based on Medical Necessity, age, and demographic characteristics.
Preventive Services Without CostSharing for Specified Services: rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for children and adolescents, additional preventive care and screenings for women. Physical Examinations for Routine Care including diagnostic services and the testing and treatment of phenylketonuria (PKU).
$0 Copayment
Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan. org
Vision and hearing screening examinations to determine the need for vision or hearing correction as provided by your PCP. Well-Woman Examinations including $0 diagnostic services, a pelvic and Copayment breast examination, and Pap smear. Annual cervical screening includes PAP tests, a human papillomavirus screening that is approved by the federal Food and Drug Administration, and the option of any cervical cancer screen test approved by the FDA (i.e. liquid based prep test). Mammography Screening for Routine Care including radiological procedures and interpretation of the results.
Call to schedule an appointment with your VHP Network PCP.
$0 Copayment
Call to schedule an appointment with your VHP Network Provider. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan. org
Your Plan Physician will order when Medically Necessary.
The age, health status, and medical needs of the Member determine the frequency of these examinations.
You may self-refer to an OB/ GYN within the VHP Network for a well-woman examination once every Calendar Year.
Frequency is based on Medical Necessity, age, and demographic characteristics. Coverage for mammography screening is limited to once every Calendar Year. Diagnostic mammograms will be covered under the “Diagnostic Laboratory Services” benefit.
33 V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M
