Blue Cross Blue Shield OK Preventive Coverage Update

Coverage Criteria and Preventive Service Rules

inv-01: Preventive claim processing criteria — General rules for preventive claims processing

General rules for preventive claims processing

Claim must include a preventive diagnosis code and a preventive procedure code to process at the preventive level with no member cost share.

Services must meet USPSTF, ACIP, HRSA, or Bright Futures guidelines and be provided by a network provider to qualify for no member cost share for members of non-grandfathered plans.

Services subject to medical policy review or prior authorization (examples include some genetic testing and certain colorectal screening services).

Preventive reimbursement requires that claims meet medical policy review criteria and correspond to the recommendations and listed procedure/diagnosis code combinations in the policy grid.

Out-of-network preventive services are subject to member cost-sharing (out-of-network benefit level applies).

inv-02: Preventive services criteria and coding — Per-service code lists and payment rules (selected examples)

Per-service code lists and payment rules (selected examples from the document):

Depression screening (adults/adolescents): CPT/HCPCS codes include 99381-99387, 99395-99397, 96160, 96161, 96127, G0444. Procedure code 96127 reimbursable at preventive level only when billed with Z00.129, Z13.31, Z13.32, Z13.39, Z13.41, or Z13.42.

Falls prevention exercise interventions: CPT codes 97110, 97112, 97116, 97150, 97161-97168, 97530; reimbursable with diagnosis Z91.81.

Folic acid preventive medication: pharmacy benefit—contact number on member card; prescription required for OTC and Rx; coverage details via pharmacy benefit.

Gestational diabetes screening: lab and specimen codes 36415, 82947, 82948, 82950, 82951, 82952, 83036; payable with a pregnancy diagnosis.

Gonorrhea screening (women): specimen/test codes 87801, 87590, 87591, 87592, 87850; payable with Diagnosis List 1 code.

inv-03: Rh(D) screening — Rh(D) incompatibility screening

Rh(D) incompatibility screening

Rh(D) blood typing and antibody testing recommended for all pregnant women at first prenatal visit (USPSTF A).

Repeat Rh(D) antibody testing at 24 to 28 weeks' gestation for unsensitized Rh(D)-negative women unless biological father is known to be Rh(D)-negative (USPSTF B).

Covered procedure/test codes include 80055, 86850, 86870, 86900, 86901, 36415; payable with a pregnancy diagnosis.

inv-04: Syphilis and tobacco cessation — Syphilis screening and tobacco cessation

Syphilis screening and tobacco cessation

Syphilis screening: USPSTF recommends screening persons at increased risk; nonpregnant screening codes include 86592, 86780, 0065U; payable with a Diagnosis List 1 code.

Syphilis screening in pregnancy: USPSTF recommends early and universal screening during pregnancy; covered codes include 80055, 80081, 86592-86593, 86780, 0065U, 36415, 0210U, 87285; payable with a pregnancy diagnosis or Diagnosis List 1.

Tobacco cessation: USPSTF recommends asking about tobacco use and providing behavioral interventions and FDA‑approved pharmacotherapy; relevant counseling and pharmacotherapy codes include 99401-99404, 99406, 99407, S9453; pharmacy benefit details require contacting the number on the member's card; two 90-day pharmacotherapy regimens allowed per benefit period; prescription required.

inv-05: Breast cancer screening — Breast cancer screening for average-risk women (HRSA)

Breast cancer screening for average-risk women (HRSA)

HRSA recommends average-risk women initiate mammography no earlier than age 40 and no later than 50, with screening at least biennially and as frequently as annually; continue through at least age 74 unless clinical factors indicate otherwise.

Screening mammography and related imaging/pathology codes include numerous CPT/HCPCS codes (e.g., 77021, 77047, 77061, 77062, 77063, 77067, 76376, 76377, 76641-76642, 77046, 77048-77049, 77065-77066, G0279 and multiple pathology codes).

Additional imaging (MRI, ultrasound, additional mammography) and pathology evaluation when indicated are recommended to complete the screening process; related codes and patient navigation codes are listed in policy.

Screening mammography procedures payable if billed with appropriate preventive diagnosis codes (e.g., Z00.00, Z00.01, Z12.31) as listed in the policy.

inv-06: Breastfeeding supports — Breastfeeding services and supplies coverage notes

Breastfeeding services and supplies coverage notes

HRSA recommends comprehensive lactation support including consultation, counseling, education, peer support, and breastfeeding equipment and supplies during antenatal, perinatal, and postpartum periods.

Covered breast pump codes include E0602 (manual), E0603 (electric), E0604 (hospital grade) and supplies A4281-A4287; G0513 and G0514 payable with a Diagnosis List 1 code; limited non-physician provider types eligible for S9443, 98960-98962.

Electric pumps (E0603) must be rented or purchased in‑network; members allowed one electric pump per benefit period; hospital grade pumps (E0604) are rental-only in-network and coverage is up to $1,000.00 or 12 months, whichever comes first; unit must be returned at end of coverage.

Retail providers (e.g., Target, Wal-Mart, online vendors) are out-of-network and out-of-network preventive coverage may include cost sharing; members may be balance billed for upgraded models.

inv-07: Contraception coverage — Contraceptive methods and counseling coverage notes

Contraceptive methods and counseling coverage notes

HRSA recommends access to the full range of FDA-approved contraceptives and contraceptive care, including screening, education, counseling, provision, and follow-up care (including immediate postpartum).

Covered services include sterilization, implants, IUDs (copper and progestin), injectables, oral contraceptives, patches, rings, diaphragms, sponges, cervical caps, condoms, spermicides, emergency contraception, and related supplies and procedures; example codes include 57170, 58300-58301, 58600-58671, 58340, 58700, 96372, 11976-11983, A4261, A4264, A4266, A4268-A4269, J7296-J7307.

Contraceptive methods that require a prescription may be covered under the member's medical or pharmacy benefit; contact the number on the member's BCBSOK card for pharmacy benefit details; procedure code 58340 reimbursable at preventive level only when accompanied by modifier 33 or specified diagnosis codes (e.g., Z30.2, Z30.40, Z30.42, Z30.49, Z98.51).

Certain implant insertion/removal codes (11981-11983) covered only when FDA-approved contraceptive implant insertion or removal is performed; coverage details and diagnosis code requirements are specified in the policy.

inv-08: Postpartum diabetes screening — Diabetes screening after pregnancy (HRSA)

Diabetes screening after pregnancy (HRSA)

Women with a history of gestational diabetes who are not currently pregnant should be screened for diabetes mellitus within the first year postpartum (as early as 4–6 weeks).

Initial postpartum testing codes include 82947-82951 and 83036; women with negative initial tests should be rescreened at least every 3 years for a minimum of 10 years after pregnancy.

Positive postpartum screening results require diagnostic confirmation testing (e.g., OGTT, fasting plasma glucose, HbA1c); repeat testing indicated if HbA1c used within first 6 months postpartum.

Postpartum diabetes screening is payable with a diagnosis code in Diagnosis List 1 per the policy.

inv-09: Preventive service payment criteria — HRSA/Bright Futures/USPSTF recommendations and payment rules

Preventive services follow HRSA/Bright Futures/USPSTF recommendations; payment rules depend on service, code and diagnosis billing.

HIV screening & counseling: recommended for ages 15+ (USPSTF A); typical codes include 87389-87391, 87806, G0432-G0435; payable with a Diagnosis List 1 code or, for pregnant persons, with a pregnancy diagnosis.

Vaccines and immunizations: multiple vaccine CPT/HCPCS codes and immunization administration codes are listed as preventive-payable; some vaccines or payments are conditioned on specific diagnosis coding (e.g., HPV payable when billed with Diagnosis List 1).

Bright Futures preventive screenings (hearing, lead, anemia, developmental, STI/HIV, dyslipidemia, etc.) have procedure codes listed; many are payable when billed with a Diagnosis List 1 code and some are age-limited for preventive payment.

Many services may be covered for diagnostic or treatment indications under other plan provisions and may be subject to member cost sharing when not meeting preventive criteria.

inv-10: Breastfeeding Equipment & Supplies Coverage — Coverage rules and limitations for breastfeeding equipment and supplies

Breastfeeding equipment and supplies coverage rules and limitations

Non-grandfathered plans provide coverage of manual (E0602), electric (E0603), and hospital grade (E0604) breast pumps and select supplies (A4281-A4286) at the preventive level.

Manual pumps (E0602) available for purchase and covered at preventive level when obtained in‑network, out‑of‑network, or retail; sales tax excluded for retail purchases; retail providers considered out-of-network for preventive services and may be subject to cost sharing.

Electric pumps (E0603) must be rented or purchased in‑network or from a contracted DME supplier; members allowed one electric pump per benefit period; upgraded models may result in balance billing for the member.

Hospital grade pumps (E0604) are covered only as rental in‑network; coverage up to $1,000.00 or 12 months, whichever comes first; unit must be returned to DME supplier at end of coverage; one breast pump allowed per benefit period.

Codes: CPT/HCPCS/ICD-10 Examples and Tables

Covered CPT Codes (COVID-19 Vaccines)CPTCovered

91318	COVID-19 vaccine, mRNA, 2-dose primary series, 30 mcg/0.3 mL dose (example)
91319	COVID-19 vaccine, mRNA, additional formulation
91320	COVID-19 vaccine, adenoviral vector
91321	COVID-19 vaccine, protein subunit
91322	COVID-19 vaccine, other
91304	COVID-19 vaccine, placeholder/administration-specific coding

Covered CPT Codes (Immunizations)CPTCovered

90696	DTaP-IPV-Hib combination vaccine
90698	DTaP vaccine, unspecified formulation
90700	DTaP, unspecified
90702	DTaP, unspecified
90723	DTaP, booster

Covered CPT Codes (Immunization Administration & Vaccines)CPTCovered

90460	Immunization administration under 18 years, first or only component, with counseling
90461	Immunization administration under 18 years, each additional vaccine
90471	Immunization administration, one vaccine (adult)
90472	Each additional vaccine (adult)
90473	Immunization administration by intranasal or oral route
90474	Each additional vaccine by intranasal or oral route
90749	Rotavirus, other formulations
96380	Unlisted therapeutic, prophylactic, or diagnostic injection; immunotherapy
96381	Unlisted therapeutic injection (additional)
90481	Immunization administration, complex (e.g., catch-up schedule)

Covered CPT Codes (COVID-19, Vaccine Series)CPTCovered

91318	See above
91319	See above
91320	See above
91321	See above
91322	See above
91304	See above

Covered CPT Codes (Vaccines Series)CPTCovered

91318	COVID-19 vaccine dose (see vaccine product coding)
91319	COVID-19 vaccine dose
91320	COVID-19 vaccine dose
91321	COVID-19 vaccine dose
91322	COVID-19 vaccine dose
91304	COVID-19 vaccine additional product code

Covered CPT Codes (DTaP Series)CPTCovered

90696	DTaP vaccine
90697	DTaP variant (if applicable)
90698	DTaP vaccine
90700	DTaP vaccine
90702	DTaP vaccine
90723	DTaP (child)

Covered CPT/Administration Codes (Immunization Admin & Injectables)mixedCovered

90460	Immunization administration with counseling (first vaccine)
90461	Each additional vaccine (under 18)
90471	Immunization administration, adults
90472	Each additional adult vaccine
90473	Intranasal/oral administration
90474	Each additional intranasal/oral
90749	Vaccine code (specific product)
96380	Therapeutic/prophylactic injection, immunotherapy
96381	Add-on injection
90481	Complex immunization administration

Covered CPT Codes (HIV PrEP Testing/Monitoring & Labs)CPTCovered

36415	Collection of venous blood by venipuncture
86689	HIV-1/2 antibody, single-step method
86701	HIV-1 antibody
86702	HIV-2 antibody
86703	HIV-1/HIV-2 combined antibody
87389	HIV-1/2 antigen/antibody combination test
87390	HIV-1/2 antigen/antibody
87391	HIV antigen/antibody
87806	HIV-1 RNA detection
G0432	Infectious disease screening (HIV) - lab related

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Covered HCPCS/J- Codes (PrEP Medications) HCPCSCovered

J0739	Cabotegravir injection, example (see pharmacy benefit for drug-specific coverage)
J0738	Cabotegravir (alternate)
J0752	Cabotegravir dosing

Covered CPT/Other (HIV PrEP Monitoring)mixedCovered

80055	Basic metabolic panel (example ordering for PrEP monitoring)
80081	Comprehensive metabolic panel
86706	HIV confirmatory testing (example)
87340	HIV-1 RNA
87341	HIV-2 RNA
80074	Other lab panels
G0499	Item/service not otherwise classified (related to prevention)
86803	HCV antibody
86804	HCV RNA
G0472	HCV screening

Covered CPT Codes (Behavioral Counseling & Screening Visits)CPTCovered

99401	Preventive medicine counseling, individual, 15 minutes
99402	Preventive medicine counseling, individual, 30 minutes
99403	Preventive medicine counseling, individual, 45 minutes
99404	Preventive medicine counseling, individual, 60 minutes
99411	Group preventive medicine counseling, 30 minutes
99412	Group preventive medicine counseling, 60 minutes

Covered E/M & Preventive Visit CodesCPTCovered

99202	Office or other outpatient visit, new patient
99203	Office new patient, moderate complexity
99204	Office new patient, high complexity
99205	Office new patient, high complexity extended

Covered Codes (Behavioral Counseling) — ExampleCPTCovered

G0444	Annual depression screening, 15 minutes
G0442	Brief behavioral counseling for alcohol misuse

Covered CPT/HCPCS Codes (Rh(D) Incompatibility)mixedCovered

80055	Electrolyte and renal function panel (commonly billed with pregnancy labs)
86850	ABO and Rh typing
86870	Antibody screen
86900	Test for other blood group antibodies
86901	Repeat antibody identification
36415	Collection of venous blood by venipuncture

Coverage NotemixedCovered

Rh(D) testing reimbursable as preventive when billed with pregnancy diagnosis codes as indicated in section

Covered CPT Codes (Syphilis Screening)CPTCovered

86592	Treponema pallidum antibody test (non-treponemal)
86780	Treponema pallidum antibody (treponemal)
0065U	Syphilis test, molecular
80055	Pregnancy panel ordering (when applicable)
80081	Comprehensive metabolic panel (when applicable)
36415	Collection of venous blood by venipuncture
0210U	Syphilis confirmatory molecular test
87285	Direct fluorescent antibody for syphilis

Coverage NotemixedCovered

Syphilis screening reimbursable as preventive when billed with appropriate diagnoses as indicated

Covered CPT/HCPCS Codes (Breastfeeding Equipment & Supplies)mixedCovered

E0602	Manual breast pump
E0603	Electric breast pump, sale or rental per policy
E0604	Hospital-grade breast pump, rental only
A4281	Breast pump tubing, replacement
A4282	Breast pump adapter, replacement
A4283	Cap for breast pump bottle, replacement
A4284	Breast shield and splash protector, replacement
A4285	Polycarbonate bottle for breast pump
A4286	Locking ring for breast pump
A4288	Breast pump accessory (added 08/29/2025)

Coverage LimitsmixedCovered

Hospital grade pump coverage cap: $1,000.00 or 12 months (rental), one electric pump per benefit period; supplies limited per group coverage

Covered CPT Codes (Cervical Cancer Screening)CPTCovered

0096U	HPV high-risk detection
87623	HPV DNA detection
87624	HPV genotyping
87625	HPV testing
88141	Cytopathology, cervical or vaginal (Pap)
88142	Cytology with manual review
88143	Cytology with automated review
88147	Cervical or vaginal cytology, manual screening
88148	Cytology with automated primary screen
88150	Cytology, screening with interpretation

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Patient Navigation ServicesCPTCovered

G0023	Patient navigation, per visit
G0024	Patient navigation, second code
G0140	Patient navigation - breast/cervical
G0146	Patient navigation - cervical

Covered CPT Codes (Contraceptive Services & Methods)CPTCovered

57170	Insertion of IUD (procedure example)
58300	Insertion of intrauterine device (IUD), unspecified
58301	Removal of intrauterine device
58600	Insertion of contraceptive implant
58605	Removal of contraceptive implant
58611	Revision of contraceptive implant
58615	Other contraceptive device procedures
58661	Insertion of IUD, postpartum
58565	Endometrial sampling
58670	Insertion/removal intrauterine device

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Coverage NotesmixedCovered

Contraceptive methods may be covered under medical or pharmacy benefit; refer to pharmacy benefit for details. Specific codes reimbursable as preventive only with required diagnosis or modifier per policy.

Covered CPT/LOINC Codes (Diabetes Screening Postpartum)CPTCovered

82947	Glucose; quantitative, blood (eg, fasting glucose)
82948	Glucose tolerance test, multiple specimen
82950	Glucose tolerance test, 3 specimen
82951	Glucose tolerance test, each additional specimen
83036	Hemoglobin; glycosylated (A1c)

Coverage NotemixedCovered

Initial testing within first year postpartum (as early as 4-6 weeks); if negative, rescreen at least every 3 years for minimum 10 years

Covered CPT Codes (Screening Lab Codes)CPTCovered

36415	Collection of venous blood by venipuncture
80055	Pregnancy panel (example)

Covered CPT Codes (Hospital Grade Pump Cap) HCPCSCovered

E0604	Hospital-grade breast pump (rental only) - coverage cap $1,000.00 or 12 months
E0603	Electric breast pump - limited to one per benefit period
E0602	Manual breast pump - retail purchase allowed (sales tax excluded)
A4281	Breast pump tubing, replacement
A4282	Adapter for breast pump, replacement
A4283	Cap for breast pump bottle, replacement
A4284	Breast shield and splash protector
A4285	Polycarbonate bottle
A4286	Locking ring
A4288	Additional pump accessory (added 08/29/2025)

Coverage Limit NotemixedCovered

Hospital grade pump coverage cap — $1,000.00 or 12 months (rental). Members allowed one pump per benefit period; at end of rental unit must be returned.

Covered CPT Codes (HIV Counseling & Screening) CPTCovered

36415	Collection of venous blood by venipuncture
86689	HIV-1/2 antibody, single-step method
86701	HIV-1 antibody test
86702	HIV-2 antibody test
86703	HIV-1/HIV-2 combined antibody
87389	HIV antigen/antibody combination test
87390	HIV confirmatory test
87391	HIV viral detection
87806	HIV-1 RNA detection
G0432	HIV screening lab

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Coverage NotemixedCovered

Payable when billed with a diagnosis code in Diagnosis List 1 or pregnancy as specified; baseline and monitoring services related to PrEP are reimbursable at preventive level.

Provider Actions, Billing Notes, and Prior Authorization

Prior Authorization

Prior Authorization May Be Required

Certain services listed in this preventive policy are subject to medical policy review and may require prior authorization before performance. Verify member eligibility and obtain any required preauthorization to avoid claim denials or member liability.

Prior authorization may be required for specific services per applicable medical policy

Prior Authorization

Lung Cancer Screening — Preauthorization Note

Low-dose CT (LDCT) lung cancer screening (e.g., G0296, 71271) is covered per USPSTF guidance but is subject to medical policy criteria and may require preauthorization. For preventive-level reimbursement of procedure code 71271, the service must meet medical policy criteria and be billed with an appropriate smoking-related diagnosis (for example: F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, Z12.2, Z87.891). Confirm preauthorization requirements before scheduling.

Affected procedure codes: G0296, 71271
If billing 71271 at preventive level, include one of: F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, Z12.2, Z87.891

Definitions and Abbreviations

United States Preventive Services Task Force — USPSTF

Full nameUnited States Preventive Services Task Force (USPSTF).

RoleSource of evidence-based preventive service recommendations referenced throughout this policy (A/B recommendations cited).

Use in policyServices recommended by USPSTF guide preventive coverage and no member cost-share for non-grandfathered plans when provided in-network.

Advisory Committee on Immunization Practices — ACIP

Full nameAdvisory Committee on Immunization Practices (ACIP).

RoleProvides immunization recommendations referenced by this policy for vaccine coverage determinations.

OpenPayer

Preventive Services Policy

Coverage Criteria and Preventive Service Rules

Codes: CPT/HCPCS/ICD-10 Examples and Tables

Provider Actions, Billing Notes, and Prior Authorization

Definitions and Abbreviations