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Routine Physical Exam

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)

Annual routine physical examinations differ from periodic health examinations, which are also covered under the Health Net Medicare Advantage (MA) and Cal MediConnect plans. An annual routine physical exam is one that is not physician-directed and is done for the purpose of checking a member's general health in the absence of symptoms. Examples include exams taken to obtain or maintain employment, licenses or insurance, or exams administered at the request of a third party, such as a school, camp or sports-affiliated organization.

One annual routine physical exam requested by the member without medical condition indications is covered along with any related X-ray and laboratory procedures ordered or approved by the physician. The exam is subject to scheduled copayments.

Routine physical exam coverage allows the member to request services not otherwise medically indicated. Refer to the specific plan in the Schedule of Benefits for routine physical examination coverage frequency based on the member's age.

In addition to annual routine physical examinations, self-referred mammograms are covered annually for female Health Net Medicare Advantage (MA) or Cal MediConnect plan members as follows:

  • One baseline exam between ages 35 and 39
  • One screening every 12 months for women ages 40 and older

This coverage does not require prior authorization or a referral from the member's participating physician group (PPG) or primary care physician (PCP). To use this coverage, the member can go to a mammography screening center affiliated with her Health Net MA or Cal MediConnect PPG or, if none is affiliated with the Health Net MA or Cal MediConnect PPG, then the member must go to a certified mammography screening center. The member can contact her Health Net PPG, the Health Net Medicare Programs Member Services Department or Cal MediConnect Member Services Department for information on claims processing and to obtain a listing of certified screening mammography centers.

Last Updated: 04/08/2021