Preventive Care Benefits Overview
List of Covered Preventive Care Services
The co-insurance for the following preventive care services from a network provider will be paid at 100%, with no deductible. Covered Preventive Care Services are subject to change. For more information see Preventive Care on pages 61-62 of the March 2020 Health Plan Summary Plan Description and its updates.
Children and Adolescents
Newborns
- Screening all newborns for
- Hearing
- Congenital Hypothyroidism
- Phenylketonuria (PKU)
- Hemoglobinopathies or Sickle cell disease
- Gonorrhea preventive medication for eyes of all newborns
Childhood/Adolescent Immunizations
- Diphtheria, Tetanus, Pertussis
- Haemophilus influenza type B
- Hepatitis A and B
- Human Papillomavirus (HPV)
- Influenza (Flu)
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal (pneumonia)
- Inactivated Poliovirus
- Rotavirus
- Varicella (chickenpox)
Childhood Screenings
- Medical history for all children throughout development
- Height, weight and Body Mass Index (BMI) measurements
- Developmental screening for children between age 9 months through 30 months
- Autism screening for children at 18 and 24 months
- Behavioral assessment for children of all ages
- Vision screening for children age 3 to 5 years
- Oral health risk assessment for young children
- Hematocrit or Hemoglobin screening for iron-deficiency anemia
- Obesity screening and weight management counseling for children age 6 or older
- Iron supplements from a network-pharmacy for children 6 to 12 months who are at higher risk for anemia (submit with a physician’s prescription directly to the Prescription Drug Plan)
- Fluoride supplements from a network pharmacy for children starting at age 6 months without fluoride in their water source (submit with physician’s prescription directly to the Prescription Drug Plan)
- Lead screening for children less than age 7 at risk of exposure
- Dyslipidemia screening for children at higher risk of lipid disorder
- Tuberculin testing for children at higher risk of tuberculosis
- Hearing Screening
Additional Screenings for Adolescents
- Depression screening
- Alcohol and drug use assessment
- Cervical dysplasia screening for sexually active young women
- Counseling to prevent sexually transmitted infections (STIs) and screening for STIs for sexually active adolescents
- HIV screening for adolescents at higher risk
Health Screenings for Adults
Miscellaneous Health Screenings
- Blood pressure screening for adults
- Screening for prediabetes and type 2 diabetes in asymptomatic adults aged 35 to 70 years who are overweight or obese. Clinicians should offer or refer patients with prediabetes to effective preventive interventions.
- HIV and sexually transmitted infections (STI) screenings for adults at higher risk
Cancer Screenings
- Breast cancer mammography allowed biennially for women aged 50 to 74 years
- Breast cancer chemoprevention counseling for women at high risk for breast cancer
- Cervical cancer pap test every three years for women age 21 through 65
- Colorectal cancer screening for adults age 45 through 75. Several recommended screening tests include:
- Colonoscopy screening every 10 years
- Flexible sigmoidoscopy every 5 years
- Flexible sigmoidoscopy every 10 year with fecal immunochemical test (FIT) every year
- CT colonography every 5 years
- Fecal immunochemical test (FIT) or high-sensitivity fecal occult blood testing (FOBT) every year
- Stool DNA-FIT every 1 to 3 years
- Low-dose computed tomography in adults age 55 to 80 who have 30 pack-year smoking history and currently smoke or have quit within the past 15 years
Other Preventive Services for Adults
- Counseling to promote a healthy diet for adults with risk factors for cardiovascular and diet-related chronic disease
- Obesity screening and – with a Body Mass Index of 30 or greater – behavioral interventions to promote sustained weight loss
- Tobacco use cessation-counseling, with or without tobacco cessation medication (submit claims for tobacco cessation medication from a network pharmacy directly to the Prescription Drug Plan with physician’s prescription and current letter from the prescribing physician to certify concurrent participation in tobacco cessation counseling)
- Alcohol misuse screening and behavioral counseling interventions in primary care to reduce alcohol misuse
- Screening for depression
- Counseling for prevention of STIs
- Counseling for use of aspirin to prevent cardiovascular disease, for males age 45 through 79 and females age 55 through 79 (submit claims for aspirin with physician’s prescription directly to the Prescription Drug Plan)
- Counseling to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk
Adult Immunizations
- Hepatitis A and B
- Herpes Zoster (Shingles) from age 60
- Tobacco use cessation-counseling, with or without tobacco cessation medication (submit claims for medication from a network pharmacy directly to the Prescription Drug Plan with physician’s prescription and current letter from the prescribing physician to certify concurrent participation in tobacco cessation counseling)
- Human Papillomavirus (HPV)
- Influenza (Flu)
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal (pneumonia)
- Tetanus, Diphtheria, Pertussis
- Varicella (chickenpox)
Screenings for Men
- Abdominal aortic aneurysm one-time screening for men age 65 to 75 who have ever smoked
Screenings for Women
- Osteoporosis screening for women age 65 and older
- BRCA counseling about genetic testing for women at higher risk and BRCA test if appropriate
- Well-woman visits, including prenatal care, to obtain recommended preventive services
- Domestic and interpersonal violence screening for all women
- Human Papillomavirus (HPV) screening every 3 years for women with normal cytology results, age 30 and over
Specifically for Pregnant Women
- FDA-approved contraceptive methods (generics only, when available). Submit claims for contraceptive drugs, devices and supplies from a network pharmacy directly to the Prescription Drug Plan, with physician’s prescription
- Folic acid supplements from a network pharmacy for women who may become pregnant (submit claims with physician’s prescription directly to the Prescription Drug Plan)
- Anemia screening for iron deficiency in pregnancy
- Tobacco cessation counseling for all pregnant women who smoke with or without pharmacotherapy (submit claims for FDA-approved medication from a network pharmacy directly to the Prescription Drug Plan with physician’s prescription and current letter from the prescribing physician to certify concurrent participation in tobacco cessation counseling)
- Hepatitis B screening during the first prenatal visit
- RH incompatibility blood type screening at first prenatal visit and 24-28 weeks
- Bacteriuria urinary tract infection screening in pregnancy at 12 to 16 weeks
- Breastfeeding education to promote breastfeeding, and breast pump and breast pump supplies
- Gestational diabetes screening for women after 24 weeks pregnant and those at high risk
