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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. 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 Care Services

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

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

(Follow-up colonoscopy after a positive stool-based test considered under the preventive benefit when billed in accordance with the preventive guidelines.)

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

Age 45-75, every 10 years

FIT-DNA (e.g., Cologuard, Cologuard Plus)

Age 45-75, every 3 years

CT Colonography (Virtual Colonoscopy)

Age 45-75, every 3 years

Depression, Anxiety and Suicide Risk Screening

Age 8 and older, three per calendar year

Diabetes Screening

Age 19 and older, every 3 years

Diet Counseling (Adults with high risk for chronic diseases)

Age 18 and older, three 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; Once per year for individuals at high risk for infection

HIV Infection Prevention: Pre-exposure Prophylaxis (PrEP)

Antiretroviral medication to be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines (ages 10 and older):

Kidney function testing (creatinine)
Hepatitis B and C testing
HIV Testing
STI screening and counseling
Pregnancy testing (when appropriate)
Adherence counseling
Associated office visits

HIV Screening (At Risk and All Pregnant Women)

Age 10 and older

Immunizations

See below for a complete list of covered immunizations

Lung Cancer Screening

Age 50-80, one per calendar year

Prostate Screening (PSA)

Men age 40 and older, one per calendar year

Preventive Office Visit

One per calendar year

Sexually Transmitted Infection (STI) Prevention Counseling

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 Screenings

Age 35-39 one baseline screening mammogram, age 40 and older one screening mammogram per calendar year
*Includes additional imaging (e.g., MRI, ultrasound, mammography) and pathology evaluation, if indicated to complete the screening process (Effective 1/1/26).

Breast Cancer Prevention Medication

Age 35 and older, pharmacy only

Breastfeeding Support

Behavioral Interventions

Twice per calendar year

Counseling and Support

Age 10 and older, five 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

Contraceptive- Medical

Age 10 and older

Contraceptive- Mobile Application

Age 10 and older, one 12-month subscription per calendar year

*Coverage includes member reimbursement for the cost of the FDA-approved, cleared, or granted mobile device applications for use an contraception consistent with FDA-approved, clear, or granted indication.

Gonorrhea Screening

Age 11 and older, twice per calendar year

Healthy Weight Gain in Pregnancy Counseling

Age 10 and older, three hours 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

Patient Navigation Services for Breast and Cervical Cancer Screening (Effective 1/1/26)

Included in preventive office visit

Perinatal Depression Prevention Interventions

Age 10 and older, three hours per calendar year

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)

With pregnancy

Preventing Obesity in Midlife Women

Age 40 to 60 years, one hour per year

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 Diabetes after Pregnancy

Age 10 and older, two per calendar year

Screening for Diabetes during Pregnancy

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 preventive office visit)

Cervical Cancer 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

Depression, Anxiety and Suicide Risk Screening

Age 8 and older, three per calendar year

Developmental Screening (< age 3)

Age birth - 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 2 months - 10 years, up to 8 tests during age range
Age 11-21, 3 tests during age range

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

High Body Mass Index in Children and Adolescents Interventions (Effective 7/1/25)

Age 6-17 years, 26 services per year

HIV Screening (adolescents at high risk)

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

Age birth - 6 months, 4 services during age range

Metabolic Hemoglobin Screening - Newborns

Age birth - 2 months, once in age range

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

Preventive Office Visit

9 visits first two years of life
Age 2, two visits (based on 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 limit

Sudden Cardiac Arrest and Sudden Cardiac Death Screening

Age 11 - 21, included in preventive office visits

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

(Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, and dosage. Refer to the CDC website to view the schedules: cdc.gov/vaccines/schedules/index.html)

Adult Tetatnus and Diphtheria Toxoids - Absorbed (Td)

COVID-19 vaccine

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)

MenABCWY (pentavalent meningococcal) vaccine

Meningococcal Conjugate Vaccine

Meningococcal Serogroup B Vaccine

Mpox Vaccine (formerly known as monkeypox)

Mumps Virus Vaccine - Live

Pneumococcal Conjugate (PCV) /Pneumococcal Polysaccharide Vaccine

Poliomyelitis Vaccine (IPV)

Respiratory Syncytial Virus (RSV) vaccine/monoclonal antibody

Rotavirus Vaccine

Rubella Virus Vaccine

Tetanus Toxoid

Tetanus, Diphtheria, Acellular Pertussis (Tdap)

Varicella (Chicken Pox) Vaccine

Zoster (Shingles) Vaccine

Pharmacy Benefits

(To be considered under the pharmacy plan when ordered by a physician and requires a prescription to be filled by the pharmacy.)

Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication

Women only age 10 and older

Contraceptives

Women only; generic only

Fluoride

Ages 6-16 years

Folic Acid

Ages 6-16 years

Breast Cancer Preventive Drugs

Women age 35 and older

Tobacco Cessation Products

Two 90-day regimens of an FDA-approved tobacco cessation medications, (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization

Iron Supplements

Ages 6-12 months

Statin Medications

Ages 40-75 years with one or more cardiovascular risk factors and calculated
10-year risk of a cardiovascular event of 10% or greater.

Prevention of HIV Infection: Pre-exposure Prophylaxis (PrEP)
(Antiretroviral medication to be considered under the pharmacy plan when ordered by a physician.)

The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines (ages 10 and older):

Kidney function testing (creatinine)
Hepatitis B and C testing
HIV testing
STI screening and counseling
Pregnancy testing (when appropriate)
Adherence counseling
Associated office visits

Revised 12/25 LR