Preventive Care Services (M)
The following preventive services and immunizations do not apply to all health plans administered or insured by your Blue Plan.  Some or all of the
 contraceptive Methods or prescription drugs listed may not be covered under the plan because of the employer’s religious beliefs.  To find out if contraceptive methods
 and prescription drugs are excluded, please contact Customer Service for additional information.   
     
If the preventive services section of your plan's benefit booklet refers to any of the preventive services and immunizations in this document, they will be covered by your health plan.  However, your group may decide to delay the effective date for coverage until your group's plan year for any new preventive services and immunizations recently added to this list.  If your plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from your office or other facility visit.  In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of your benefit booklet may apply.  In any case, applicable office visit or facility copayments may still apply when the primary purpose for your visit is not routine preventive services and/or routine immunizations. When seeing a provider outside the state, please ask the provider to contact your Health Plan to verify the procedure and diagnosis codes that are covered under these preventive services. If you have any questions about your plan’s benefits, you may also call our Customer Service Department at the number on the back of your ID card.       
Contact your group benefit administrator for information regarding the effective date of new preventive services and immunization recently added to the list below.      
Healthcare Reform Preventive Services  Frequency      
       
Preventive Services for Adults      
Abdominal Aortic Aneurysm Screening Age 65-75 one screening per lifetime  (men only with any history of smoking)      
Alcohol Misuse Screening and Behavioral Counseling Interventions One per calendar year      
Ambulatory Blood Pressure Monitoring Once per lifetime to confirm the diagnosis of hypertension      
Aspirin Use Counseling for CVD Prevention Men age 50-59, Women age 13-59 every 5 years      
Behavior Counseling to Prevent Skin Cancer Age 6 months - 24 years (included in E&M and/or preventive office visit)      
Blood Pressure Screening Age 18 and older, one per calendar year (Included as part of an office visit)      
Cholesterol Screening Men age 35 and older (20-35 at risk for CAD), Women age 45 and older  (20-45 at risk for CAD) every 5 years        
Colorectal Cancer Screening        
     Fecal occult blood testing Age 45-75 , one per calendar year      
     Sigmoidoscopy Age 45-75 , every 3 years      
     Colonoscopy Age 45-75 , every 10 years      
     Barium Enema Age 45-75 , every 5 years      
     Pre-Screening Consultation Effective January 1, 2016
Age 45-75 , every 10 years
     
     FIT-DNA (Cologuard™) Age 45-75, every 3 years      
Depression Screening Age 11 and older, one per calendar year      
Diabetes Screening (Type 2 for adults with high blood pressure) Age 19 and older, every 3 years      
Diet Counseling (Adults with high risk for chronic diseases) Age 18 and older, 3 hours each calendar year      
Fall Prevention Screening Age 65 and older. Exercise, physical therapy and vitamin D supplementation      
Hepatitis B Screening Age 11 and older, one per calendar year      
Hepatitis C Screening Once per lifetime, as recommended per guidelines      
HIV Screening (At Risk and All Pregnant Women) Men age 11 and older   
Women age 10 and older
     
Immunizations  See  below for a complete list of covered immunizations      
Lung Cancer Screening Effective January 1, 2015
Age 50-80, one per calendar year
     
Obesity Screening and Counseling Age 6 and older, one per calendar year       
Prostate Screening (PSA) Men age 40 and older, one per calendar year      
Psychosocial/Behavioral Assessment Age Newborn - 21 years, 31 services during age range      
Routine Office Visit One per calendar year      
Sexually Transmitted Infection (STI) Prevention Counseling Men age 11 and older, 3 services in a lifetime
Women age 10 and older, one per calendar year
     
Tobacco Use Counseling Age 6 and older, 8 per calendar year      
Tuberculosis Infection Screening Age 19 and older (adults at risk), one per calendar year      
Preventive Services for Women (Including Pregnant Women)      
Bacteriuria (Pregnant Women) With pregnancy      
BRCA Counseling about genetic testing for women at higher risk Once in a lifetime      
Breast Cancer Chemoprevention Counseling Once in a lifetime      
Breast Cancer Mammography Screenings  Age 35-39, one baseline
Age 40 and older, one per calendar year
     
Breast Cancer Prevention Medication Age 35 and older, pharmacy only      
Breast Feeding        
     Behavioral Interventions Twice per calendar year      
     Counseling and Support Age 10 and older, three per year in conjunction with a birth      
     Supplies - Pumps and Accessories Age 10 and older, one electric breast pump allowed per pregnancy      
Cervical Cancer Screening (Pap Smear) One per calendar year      
Chlamydia Screening Age 15 and older, one per calendar year      
Contraceptive Methods and Counseling                                        
     Counseling Age 10 and older, one annually      
     Sterilization Age 10 and older, one procedure per lifetime      
     Confirmatory Test Two per lifetime      
     Medical Contraceptive Age 10 and older      
Gonorrhea Screening Age 11 and older, twice per calendar year      
Hepatitis B Screening One per calendar year for pregnant women      
HIV Screening (At Risk and All Pregnant Women) Age 10 and older      
HIV Counseling Age 10 and older, one per calendar year      
Human Papillomavirus (HPV) Screening Age 30 and older, every 3 years      
Iron Deficiency Anemia Screening One per calendar year for pregnant women      
Osteoporosis Screening  Age 65 and older, 65 and younger if at risk, once every 2 years      
Preconception Visit Age 10 and older, one visit per calendar year      
Prenatal Care Age 10 and older, up to six visits per calendar year depending on diagnosis and procedure      
Preeclampsia Screening Age 10 and older (included in prenatal office visit)      
Prenatal Conference (Pediatrician only)        
Rh Incompatibility Screening (All Pregnant Women) Twice per calendar year      
Screening and Counseling for Interpersonal and Domestic Violence Age 10 and older, one per calendar year      
Screening for Gestational Diabetes Age 10 and older, two per calendar year      
Sexually Transmitted Infection (STI) Prevention Counseling Age 10 and older, one per calendar year      
Syphilis Screening (At Risk and All Pregnant Women) No frequency limit      
Tobacco Use Counseling (Pregnant Women) Age 10 and older, 8 per calendar year      
Well Women Visit Age 10 and older, up to two visits per calendar year depending on diagnosis and procedure      
Preventive Services for Children      
Alcohol and Drug Use Assessments (Adolescents) Age 11-21, one per calendar year      
Behavior Counseling to Prevent Skin Cancer Age 6 months - 24 years (included in E&M and/or preventive office visit)      
Cervical Dysplasia Screening  (Pap Smear) one per calendar year      
Congenital Hypothyroidism (Newborns) Age 2-4 days      
Dental Caries Prevention (< age 5) Age birth - 5 years, 4 per calendar year      
Dental Caries Prevention (Preschool Children) Included in preventive office visit      
Developmental Screening (< age 3) Age 9-30 months, 5 screenings      
Developmental Surveillance Included as part of an office visit      
Dyslipidemia Age 2-10, one every 2 years
Age 11-17, one per calendar year
Age 18-21, once during age range
     
Gonorrhea Prevention (eye meds for newborns) At delivery, included in standard inpatient newborn care      
Hearing Screening - Newborns Age birth - 31 days, once in age range      
Hearing Screening  Age 11-21, 3 tests during age range      
Height, Weight and BMI Measurements  Included as part of an office visit      
Hematocrit or Hemoglobin Screening Age 4 months - 10 years, 3 services during age range
Age 11-21, one per calendar year
     
Hemoglobinopathies (sickle cell screening for newborns) Age birth - 31 days      
Hepatitis B Screening Age 11 and older, one per calendar year      
HIV Screening (adolescents at high risk) Men age 11 and older   
Women age 10 and older
     
Immunizations See  below for a complete list of covered immunizations      
Lead Screening Age 6 months - 6 years, 3 services during age range      
Maternal Depression Screening Effective January 1, 2017
Age birth - 6 months, 4 services during age range
     
Metabolic Hemoglobin Screening - Newborns Age birth - 2 months, once in age range      
Obesity Screening and Counseling Age 6 and older, one per calendar year      
Oral Health Risk Assessment Age 6 months - 6 years, 3 services during age range       
Routine Newborn Care (in hospital) Included in standard inpatient newborn care      
Phenylketonuria (PKU - for newborns) Age 2-14 days, 2 services during age range      
Psychosocial/Behavioral Assessment Age Newborn - 21 years, 31 services during age range      
Routine Office Visit 9 visits first two years of life
Age 2, two visits per birth year
Age 3-6, one each year (based on birth year)
Age 7 and older, one visit per calendar year
     
Sexually Transmitted Infections counseling (STI - adolescents at high risk) Age 10 and older, one per calendar year      
Sexually Transmitted Infections Screening (STI - adolescents at high risk) Age 11 - 21, no frequency      
Tuberculin Testing Age 1 month - 21 years, 6 services during age range      
Vision Screening (Visual Acuity) Birth - 10 years, 8 services in age range
Age 11-21, 4 services in age range
     
 Immunizations*        
For recommendations and guidelines regarding the following immunizations, go to www.cdc.gov/vaccines/recs/schedules
(immunizations must be given by a network provider who is authorized by your plan to provide these services)
     
Adult Tetanus and Diphtheria Toxoids - Absorbed (Td)        
Diphtheria Toxoid        
Diphtheria, Tetanus (DT)        
Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Hemophilus Influenza Type B, and Poliovirus Vaccine, Inactivated (DTaP-Hib-IPV)        
Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Hepatitis B, and Poliovirus Vaccine, Inactivated (DTaP-HepB-IPV)        
Diphtheria, Tetanus, Acellular Pertussis (Dtap)        
Diphtheria, Tetanus, Acellular Pertussis and Hemophilus Influenza B Vaccine (DTaP-Hib)        
Diptheria, Tetanus Toxoids, Acellular Pertussis Vaccine and Poliovirus Vaccine, Inactivated (Dtap-IPV)        
Hemophilus Influenza B Vaccine (HIB)        
Hepatitis A        
Hepatitis A and B        
Hepatitis B and Hemophilus Influenza B Vaccine - Active Immunization (HepB - Hib)        
Hepatitis B Vaccine - Active Immunizations (HepB)        
Human Papilloma Virus (HPV) Vaccine        
Influenza Virus Vaccine        
Measles Virus Vaccine - Live        
Measles, Mumps and Rubella Vaccine (MMR)        
Measles, Mumps, Rubella, and Varicella Vaccine (MMRV)        
Meningococcal Conjugate Vaccine        
Meningococcal Serogroup B Vaccine        
Mumps Virus Vaccine  - Live        
Pneumococcal Conjugate (PCV) /Pneumococcal Polysaccharide Vaccine        
Poliomyelitis Vaccine (IPV)        
Rotavirus Vaccine        
Rubella Virus Vaccine        
Tetanus Toxoid        
Tetanus, Diphtheria, Acellular Pertussis (Tdap)        
Varicella (Chicken Pox) Vaccine        
Zoster (Shingles) Vaccine        
* Before getting one of the above immunizations at a pharmacy, ask the pharmacist if your pharmacy benefit will cover the immunizations at no cost to you. Otherwise, to receive the immunization at 100% and no cost sharing you will need to go to an in-network physician.

Women's Health and Cancer Rights Act Information:  A member who is receiving benefits in connection with a mastectomy will also receive coverage for reconstruction of the breast on which a mastectomy was performed and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications at all stages of the mastectomy, including lymphedema.  Benefits for this treatment will be subject to the same calendar year deductible and coinsurance provisions that apply for other medical and surgical benefits.

Benefits for mammograms vary depending upon the reason the procedure is performed and the way in which the provider files the claim:

• If the mammogram is performed in connection with the diagnosis or treatment of a medical condition, and if the provider properly files the claim with this information, we will process the claim as a diagnostic procedure according to the benefit provisions of the plan dealing with diagnostic X-rays.
• If you are at high risk of developing breast cancer or you have a family history of breast cancer   within the meaning of our medical guidelines – and if the provider properly files the claim with this information, we will process the claim as a diagnostic procedure according to the benefit provisions of the plan dealing with diagnostic X-rays.
• In all other cases the claim will be subject to the provisions and limitations described within your booklet, including the section called Physician Preventive Benefits.
     
         
Revised  7/9/21 YPE