Diebold Agency Logo A Distinguished Member of the Sitkins 100

Community Blue Benefits!

**See your contract for Specific Deductibles**

Taken from Blue Cross/Blue Shield Rate Ease Rating Program - September 2005

Benefits In-Network Out-of-Network
Health Maintenance Exam:
includes chest X-ray, EKG and
select lab procedures 		Covered 100%: **
One per calendar year 		Not Covered
Gynecological Exam:
 Covered 100%: **
One per calendar year 		Not Covered
Pap Smear Screening:
laboratory and pathology services 		Covered 100%: **
One per calendar year 		Not Covered
Well-Baby and Child Care:
 Covered 100%: **
  • 6 visits - birth thru 12 mos.
  • 6 visits - 13 mos. thru 23 mos.
  • 2 visits - 24 mos. thru 35 mos.
  • 2 visits - 36 mos. thru 47 mos.
  • 1 visit per birth yr. - 48 mos. thru 15 yrs.
 Not Covered
Benefits In-Network Out-of-Network
Immunizations:
 Covered 100%: **
up through age 16 		Not Covered
Fecal Occult Blood Screening:
 Covered 100%: **
One per calendar year 		Not Covered
Flexible Sigmoidoscopy:
 Covered 100%: **
One per calendar year 		Not Covered
Prostate Specific Antigen
(PSA) Screening:
 Covered 100%: **
One per calendar year 		Not Covered
Mammography Screening:
 Subject to deductible
and co-insurance 		Subject to deductible
and co-insurance
** Payment for preventive services is limited to a combined maximum
of $500 per member per calendar year
©2005 Diebold Insurance Agency - All rights reserved