Preventive services
                                    GM salaried employees
    As a General Motors employee with Blue Cross Blue Shield of Michigan health benefits, you have certain 
    preventive services covered. This includes certain cancer screenings, annual physicals and routine vaccines. 
    Providing preventive health care is one more way that GM is helping improve the health of its employees while 
    managing health care costs.
    Preventive health services guidelines
    GM health care plans cover 100% of the cost of certain preventive services and immunizations when provided 
    by an in-network provider (or a Level 1 provider for ConnectedCare). This means that some members don’t 
    need to pay a copayment or coinsurance when receiving these services.
    Why is preventive care so important?
    Visiting your provider regularly for checkups can keep you healthy by detecting potential health problems 
    while they can still be prevented – or easily treated. This can prevent serious and costly medical conditions 
    down the road. 
    What types of services are not considered preventive?
    Services are not considered preventive when they are for an existing illness or injury. If a service isn’t 
    considered preventive, your share of the costs may still apply (such as the usual deductible, copayment  
    or coinsurance). 
     Following are some of the major preventive services that currently must be covered with no cost sharing when you 
     get them from a network or Level 1 provider. This is not a comprehensive list of all the services, so please refer to the 
     websites noted at the end of this brochure for further details. Your benefit plan will determine your specific coverage 
     for these benefits. Your coverage may vary from the types of benefits listed below.
      Annual health maintenance exams (HME)                    Frequency 
      Health maintenance examination                           Eight visits for first 12 months; six visits from age 13 to 23 months; six 
      (physical exam; adults and well baby/children)           visits from age 24 to 35 months; two visits per 12 months from age 36 to 
                                                               47 months; 1 visit per 12 months from age 48 months to adult
      Well-visits for adults                                   One per calendar year
      Annual obstetrician-gynecologist exam                    Two per calendar year in addition to HME (physical)
      Well-woman visits                                        One HME per calendar year and two OB/GYN per calendar year (not 
                                                               separate from the HME and annual exam described above)
      Services included in annual health                       Frequency 
      maintenance exams (well-visits for adults) 
      Consultation for aspirin for the prevention of           One per calendar year 
      cardiovascular disease
      Consultation for folic acid                              One per calendar year
      Behavior counseling to prevent skin cancer               One per calendar year
      Counseling for breast and ovarian cancer                 One per calendar year
      susceptibility, genetic risk assessment and BRCA 
      mutation testing (see “BRCA testing”)
      Depression screening                                     One per calendar year
      Electrocardiograms                                       One per calendar year
      High blood pressure screening and counseling             One per calendar year
      Obesity screening and counseling                         –  Screening: one per calendar year
                                                               –  Nutrition counseling services: six per calendar year
                                                               –  Intensive counseling for persons with BMI of 30 and over: up to 26 per 
                                                                  calendar year
                                                               –  Face-to-face group counseling for persons with BMI of 30 and over: up 
                                                                  to 12 per calendar year
      Fall-prevention recommendations for older adults,        One per calendar year
      which may include exercise, physical therapy, or 
      Vitamin D supplementation
      Sexually transmitted infection screening and             Two per calendar year
      counseling (if sexually active)
      Discuss chemoprevention when at high risk for            One per calendar year
      breast cancer
      Counseling for adults with high risk of cardiovascular   –  Screening: one per calendar year
      disease                                                  –  Counseling services: six per calendar year
                                                               –  Intensive counseling for persons with BMI of 30 and over: up to 26 per 
                                                                  calendar year
                                                               –  Glucose testing: twice per calendar year
                                                               –  Dyslipidemia testing: once per calendar year
                                                               –  Tobacco cessation counseling
                                                               GM preventive services
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      Services included in annual health                      Frequency 
      maintenance exams (well-baby and well-child)
      Developmental surveillance                              Eight visits for first 12 months; six visits from age 13 to 23 months; six 
                                                              visits from age 24 to 35 months; two visits per 12 months from age 36 to 
                                                              47 months; 1 visit per 12 months from age 48 months to adult
      Discussions of concerns (anticipatory guidance) —       Eight visits for first 12 months; six visits from age 13 to 23 months; six 
      Opportunities to discuss issues of concern regarding    visits from age 24 to 35 months; two visits per 12 months from age 36 to 
      bicycle safety, weight maintenance, smoking, obesity,   47 months; 1 visit per 12 months from 48 months to adult
      and the media’s influence on children and adolescents. 
      Refer to the American Academy of Pediatrics/Bright 
      Futures website for more details.
      Psychosocial/behavioral assessment                      Eight visits for first 12 months; six visits from age 13 to 23 months; six 
                                                              visits from age 24 to 35 months; two visits per 12 months from age 36 to 
                                                              47 months; 1 visit per calendar year from 48 months to adult
      Screening for major depressive disorders in             One per calendar year
      adolescents
      Obesity screening and counseling, children              –  Screening: one per calendar year
                                                              –  Nutrition counseling: six per calendar year
                                                              –  Face-to-face counseling visits: 12 per calendar year (for persons with  
                                                                 a BMI of 30 and over)
                                                              –  Intensive behavioral counseling: 26 per calendar year (for persons  
                                                                 with a BMI of 30 and over)
      General oral exam                                       Eight visits for first 12 months; six visits from age 13 to 23 months; six 
                                                              visits from age 24 to 35 months; two visits per 12 months from age 36 to 
                                                              47 months; 1 visit per 12 months from 48 months to adult
                                                              Note: This service is provided by your physician, not your dentist.  
                                                              Your physician may recommend separate follow-up visits with the dentist, 
                                                              if needed.
      Consultation for cavity prevention in preschool         Eight visits for first 12 months; six visits from age 13 to 35 months;  
      children                                                two visits per calendar year from age 36 to 47 months; 1 visit per calendar 
                                                              year from 48 months to adult
                                                              Note: This service is provided by your physician, not your dentist.  
                                                              Your physician may recommend separate follow-up visits with the dentist, 
                                                              if needed.
      Autism screening (18 and 24 months)                     Eight visits first 12 months; than six visits per calendar year to age  
                                                              24 months.
      Alcohol and drug use assessment                         One visit per calendar year from age 11 to 21 years
      Critical congenital heart disease screening             1 per calendar year; zero to 30 days old
      Venipuncture                                            No limit for routine
                                                             GM preventive services
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      Immunizations                                        Ages 0 to 6 years          Ages 7 to 18 years          Age 19 years and over 
      Cholera                                                                         X (age 18)                  X (ages 19 to 64)
      Influenza                                            X                          X                           X
      Influenza virus vaccine, split virus, preservative-                                                         X (age 65 and over)
      free, enhanced immunogenicity via increased 
      antigen content, for intramuscular use
      Pneumococcal                                         X                          X                           X (age 65 and up; 19 to 64  
                                                                                                                    if at risk)
      Tetanus, diphtheria, pertussis (IPV, Hib)            X                          X                           X
      Hepatitis A                                          X                          X                           X (if at risk)
      Hepatitis B                                          X                          X                           X (if at risk)
      Human papillomavirus (HPV)                                                      X (starting at age 9)       X (through age 45)
      Measles, mumps, rubella (varicella)                  X                          X                           X (ages 19 to 59)
      Meningococcal                                        X (if at risk)             X  (10 years & older or     X (if at risk)
                                                                                         if at risk)
      Japanese Encephalitis                                X (2 months and older)     X                           X
      Zoster (shingles)                                                                                           X (age 60 and over) 
      Shingrix (shingles)                                                                                         X (age 50 and over)
      Rotavirus                                            X (ages 2 to 6 months)
      Inactivated polio                                    X                          X 
      Varicella (chicken-pox)                              X                          X                           X (19 to 65 years)
      Influenza type b (Hib)                               X  (ages 2 months          X (if at risk)              X (if at risk)
                                                             to 5 years)
     Note: Immunizations include the fees for the administration of the vaccines.
      Assessments, screenings                            Frequency                                   Children and           Adults 
      and counseling                                                                                 adolescents
      Abdominal aortic aneurysm, one-time                One per lifetime                                                   X (ages 65 to 75)
      ultrasonography screening for smokers
      Alcohol misuse screenings and behavioral           Frequency aligns with mental health         X                      X
      counseling interventions for those at risk         parity regulations
      to reduce alcohol misuse (for adults age 18 
      or older)
      Asymptomatic bacteriuria in pregnant women,  Two per calendar year                             X                      X
      screening 
      BRCA testing                                       One per lifetime                            X                      X
      Prostate cancer screening                          Once per calendar year                      X                      X
      Mammography (including 3D 3/1/18) for              One per calendar year                                              X (ages 50 to 74)
      breast cancer screening
      Telephone support for breastfeeding                Two per calendar year                       X                      X
      Cervical cancer screening or cervical              One per calendar year                       X                      X
      dysplasia screening
      Chlamydia infection screening                      One per calendar year                       X                      X
      Colorectal cancer screening (fecal occult,         One of each per calendar year                                      X (ages 50 to 
      sigmoidoscopy, colonoscopy)                                                                                           75 or younger 
      Colonoscopy includes one pre-service office                                                                           if high risk) 
      visit and surgical pathology
      Congenital hypothyroidism screening                One per calendar year                       X (newborns only)
      Developmental screening                            Two per calendar year                       X (9 to 30 months)
      Diet behavioral counseling in primary care for  Six per calendar year                          X                      X
      adults with hyperlipidemia and other known 
      risk factors for cardiovascular and diet-related 
      chronic disease
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