angle-left 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

Effective November 1, 2016
Once per lifetime to confirm the diagnosis of hypertension

     

Aspirin Use Counseling for CVD Prevention

Men age 45-79, Women age 55-79 every 5 years
Effective July 1, 2016
Men age 50-59, Women age 13-59 every 5 years

     

Behavior Counseling to Prevent Skin Cancer

Age 10-24. Counseling for children, adolescents and young adults with fair skin
Effective April 1, 2019
Age 6 months - 24 years (included in E&M and/or preventive office visit)

     

Blood Pressure Screening

Age 18 and older (Usually included in the office visit)
Effective November 1, 2016
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 50-75, one per calendar year

     

Sigmoidoscopy

Age 50-75, every 3 years

     

Colonoscopy

Age 50-75, every 10 years

     

Barium Enema

Age 50-75, every 5 years

     

Pre-Screening Consultation

Effective January 1, 2016
Age 50-75, every 10 years

     

Bowel Prep

Effective July 01, 2016
Age 50-75

     

FIT-DNA (Cologuard™)

Effective November 1, 2017
Age 50-75, every 3 years

     

Depression Screening

Age 12 and older, one per calendar year
Effective January 1, 2015
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 19 and older, 3 services each calendar year

     

Fall Prevention Screening

Age 65 and older. Exercise, physical therapy and vitamin D supplementation

     

Hepatitis B Screening

Effective June 1, 2015
Age 11 and older, one per calendar year

     

Hepatitis C Screening

Once per lifetime screening for males and females born 1945 through 1965 OR for anyone born to an HCV-infected mother OR Once per year for males and females at high risk for infection

     

HIV Screening (At Risk and All Pregnant Women)

Age 11 and older
Effective August 1, 2012
Women age 10 and older

     

Immunizations

See below for a complete list of covered immunizations

     

Lung Cancer Screening

Effective January 1, 2015
Age 55-80, one per calendar year

     

Major Depressive Disorder Screening

Age 12 and older, one per calendar year
Effective January 1, 2015
Age 11 and older, 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

Effective January 1, 2015
Age Newborn - 21 years, 31 services during age range

     

Routine Office Visit

One per calendar year

     

Sexually Transmitted Infection (STI) Prevention Counseling

Age 11 and older, 3 services in a lifetime
Effective August 1, 2012
Women age 10 and older, one per calendar year

     

Tobacco Use Counseling

Age 19 and older, limited to two per calendar year
Effective January 1, 2011 - May 15, 2014
Age 19 and older, 4 per calendar year

Effective May 16, 2014 - August 31, 2014
Age 19 and older, 8 per calendar year

Effective September 1, 2014
Age 6 and older, 8 per calendar year

     

Tuberculosis Infection Screening

Effective October 1, 2017
Age 19 and older (adults at risk), one per calendar year

     

Preventive Services for Women (Including Pregnant Women)

     

Bacteriuria (Pregnant Women)

   

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

     

Digital Breast Tomosynthesis

Effective November 1, 2017
Included with routine mammogram

     

Breast Cancer Prevention Medication

Effective October 1, 2014
Age 35 and older, pharmacy only

     

Breast Feeding

     

Behavioral Interventions

Twice per calendar year

     

Counseling and Support

Effective August 1, 2012
Age 10 and older, three per year in conjunction with a birth

     

Supplies - Pumps and Accessories

Effective August 1, 2012
Age 10 and older

     

Cervical Cancer Screening (Pap Smear)

One per calendar year

     

Chlamydia Screening

Age 15 and older, one per calendar year

     

Contraceptive Methods and Counseling

     

Counseling

Effective August 1, 2012
Age 10 and older, one annually

     

Sterilization

Effective August 1, 2012
Age 10 and older, one procedure per lifetime

     

Confirmatory Test

Effective August 1, 2012
Two per lifetime

     

Medical Contraceptive

Effective August 1, 2012
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)

Effective August 1, 2012
Age 10 and older

     

HIV Counseling

Effective August 1, 2012
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

Effective October 1, 2010 - January 31, 2012
Age 65 and older, 60 and older if at risk, once every 4 years
Effective February 1, 2012
Age 65 and older, 65 and younger if at risk, once every 2 years

     

Preconception Visit

Effective August 1, 2012
Age 10 and older, one visit per calendar year

     

Prenatal Care

Effective August 1, 2012
Age 10 and older, up to six visits per calendar year depending on diagnosis and procedure

     

Preeclampsia Screening

Effective May 1, 2018
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

Effective August 1, 2012
Age 10 and older, one per calendar year

     

Screening for Gestational Diabetes

Effective August 1, 2012
Age 10 and older, two per calendar year

     

Sexually Transmitted Infection (STI) Prevention Counseling

Effective August 1, 2012
Age 10 and older, one per calendar year

     

Syphilis Screening (At Risk and All Pregnant Women)

     

Tobacco Use Counseling (Pregnant Women)

Age 10 and older, limited to two per calendar year
Effective January 1, 2011 - May 15, 2014
Age 10 and older, 4 per calendar year
Effective May 16, 2014
Age 10 and older, 8 per calendar year

     

Well Women Visit

Effective August 1, 2012
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 10-24. Counseling for children, adolescents and young adults with fair skin
Effective April 1, 2019
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)

Effective June 1, 2015
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, 4 screenings
Effective January 1, 2015
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)

     

Hearing Screening - Newborns

Age birth - 31 days, once in age range

     

Hearing Screening

Age 2 months - 10 years, 8 tests during age range
Age 11-21, 2 tests during age range

Effective May 1, 2017
Age 11-21, 3 tests during age range

     

Height, Weight and BMI Measurements

Usually included with 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

Effective June 1, 2015
Age 11 and older, one per calendar year

     

HIV Screening (adolescents at high risk)

Age 11 and older
Effective August 1, 2012
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

     

Major Depressive Disorder Screening

Age 12 and older, one per calendar year
Effective January 1, 2015
Age 11 and older, one per calendar year

     

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)

     

Phenylketonuria (PKU - for newborns)

Age 2-14 days, 2 services during age range

     

Psychosocial/Behavioral Assessment

Effective January 1, 2015
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 11 and older, 3 services in a lifetime
Effective August 1, 2012
Women 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 (types 16 and 18); Cervarix® (HPV)

     

Human Papilloma Virus (types 6, 11, 16 and 18); Gardasil® (HPV)

     

Influenza Virus Vaccine

FluMist is included as a covered influenza virus vaccine (Coverage is limited based on the specific FDA labeling)

     

Measles Virus Vaccine - Live

     

Measles, Mumps and Rubella Vaccine (MMR)

     

Measles, Mumps, Rubella, and Varicella Vaccine (MMRV)

     

Meningococcal Conjugate Vaccine

     

Meningococcal Polysaccharide 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 10/8/18