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Routine Physical Exam

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)

Coverage for a routine physical examination is optional coverage that an employer group may purchase. Routine physical examinations differ from periodic health evaluations, which are covered by all plans.

Routine physical exams requested by the member without medical condition indications, along with any related X-ray and laboratory procedures ordered or approved by the physician, may be covered. X-ray and laboratory procedures may be subject to a calendar-year deductible if they are not billed and coded in relation to a routine physical examination. Examinations are subject to scheduled copayments.

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

A routine physical examination 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.

Assistance with completing any related forms is not covered. The only exception is completion of a Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Referral form. Refer to the Referrals to WIC discussion for additional information.

Last Updated: 10/29/2019