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 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
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

Age 45-75 , every 10 years
  • FIT-DNA (Cologuard™)
Age 45-75, every 3 years
  • CT Colonography (Virtual Colonoscopy) 
Age 45-75, every 3 years
Depression Screening Age 11 and older, one 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, 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 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.

Effective 9/17/21, 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) Men age 11 and older   
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
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
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 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
Breastfeeding Support
  • 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
Healthy Weight Gain in Pregnancy Counseling (effective 6/1/22) 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
Perinatal Depression Preventive 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
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 2 months - 10 years, up to 8 tests during age range
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) 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
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
Preventive 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 limit
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 *

*Immunizations must be given by a network provider who is authorized by your plan to provide these services. For recommndations and guidelines regarding the following immunizations, visit www.cdc.gov/vaccines/recs/schedules 

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 

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 Men age 50-59; Women age 13-59 every 5 years
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 Medication 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. 

Effective 9/17/21, 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  04/19/22 LR