Preventive Care Benefits (Preventive Services & Screening Coverage Criteria)
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Defines preventive and wellness services covered (deductible and coinsurance waived) for applicable lines of business, including covered screenings, immunizations, counseling, contraceptives, and select prescription preventive medications for Blue Cross Blue Shield - Wyoming members.
No material clinical or coverage changes in this revision.
Covered Preventive Services
Covered Preventive Services and Frequencies
Covered preventive services (deductible and coinsurance waived) when performed by an in‑network provider.
Frequency and age-specific services listed in source
See source for age ranges and visit limits
See source for visit limits and pregnancy-specific services
See source for population specifications
See source for modality‑specific frequencies
See source for age ranges and included medications
See source for visit limits and covered counseling topics
Brand vs generic and copay rules specified in source
Benefits other than those specifically outlined in this document will not be covered as a preventive or wellness benefit. These benefits meet the criteria of the Patient Protection and Affordable Care Act (PPACA) for wellness and preventive benefits; any service not listed below is excluded from preventive/wellness coverage and may be subject to standard benefit determination and cost-sharing.
Age and Frequency Thresholds / Coding Notes
Provider Requirements and Billing Notes
Documentation and Network Provider Requirement
Services must be documented as preventive/wellness and performed by a Participating/In‑Network/Health Fair Provider to qualify for waived cost‑sharing. Nonparticipating or non‑network services are not covered as preventive and deductible/coinsurance may apply.
- Services must be performed by a Participating, In‑Network, or Health Fair Provider
- Nonparticipating / non‑network services are not covered as preventive
Brand vs. Generic Preventive Drugs
If a brand preventive drug is prescribed when an equivalent generic is available, the participant must pay the cost difference between the brand and the generic. Brands will otherwise pay at the plan's normal benefit level unless the prescriber provides documentation showing the brand is medically necessary for preventive use.
- $0 copay for generics when covered as preventive (no preventive diagnosis required)
- Participant pays difference if choosing brand over available generic
- Brand may be covered at preventive level only if documentation shows brand is prescribed for preventive use and explains medical rationale
Definitions
Background and Guiding Authorities
This document lists the preventive services and frequencies that satisfy PPACA and related federal guidance, specifically recommendations by the U.S. Preventive Services Task Force (USPSTF) (A/B), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and Bright Futures. When performed by a Participating/In‑Network or Health Fair Provider, the listed preventive services have deductible and coinsurance waived as described in the schedule below.
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