CurrentBlue Cross Blue Shield - WyomingPolicy N/A

Preventive Care Benefits — Coverage Criteria

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Defines preventive and wellness services covered (deductible and coinsurance waived) for applicable Blue Cross Blue Shield - Wyoming plans; applies to services delivered by participating/network providers or health fairs and when plan's preventive definition includes USPSTF A/B, ACIP, HRSA, and Bright Futures recommendations.

Policy Summary

PayerBlue Cross Blue Shield - Wyoming

PolicyPreventive Care Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPerform preventive services only when delivered by a participating/network provider or health fair and confirm benefit applicability in the member's benefit document.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Deductible waivedcost-sharing for covered preventive services

45-75colorectal screening age range

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CurrentBlue Cross Blue Shield - WyomingPolicy N/A

Preventive Care Benefits — Coverage Criteria

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Know when Blue Cross Blue Shield - Wyoming releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - Wyoming

PolicyPreventive Care Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPerform preventive services only when delivered by a participating/network provider or health fair and confirm benefit applicability in the member's benefit document.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Deductible waivedcost-sharing for covered preventive services

45-75colorectal screening age range

Covered Preventive Services & Scope

Covered Preventive Services

Covered preventive services (deductible and coinsurance waived) when performed by participating providers and when applicable under the member's preventive benefits definition.

General eligibility: Service is a preventive service recommended by USPSTF (A/B), ACIP, HRSA, Bright Futures or listed in this policy and the member's plan preventive definition includes those recommendations

Services must be delivered by participating providers or at approved health fairs

Pediatric well-child schedule: Newborn through 6th birthday: newborn blood screening; prophylactic ocular topical medication for prevention of gonococcal ophthalmia neonatorum; scheduled well visits (birth-12 months: 7 visits; 13-35 months: 4 visits; 36-72 months: 1 visit per calendar year); immunizations per CDC; congenital hypothyroidism screening under age 1; newborn bilirubin screening; PKU screening once in first year; sickle cell screening up to age 1; hematocrit/hemoglobin through age 1; hearing screening up to 1 month; lead screening through age 6; developmental and autism screening through age 2; oral health screening; fluoride varnish from birth through age 6 (applied by primary care clinicians)

Well-child and adolescent screenings through age 21: Sensory vision screening 1 per calendar year; sensory hearing screening 1 per calendar year through age 21 (in addition to newborn hearing); tuberculin testing; behavioral/social/emotional screening

Age-based adult preventive services: Routine physical examinations for participants age 6 and older (office visit) and well-woman preventive visits as medically appropriate; aortic aneurysm screening for males age 65-75 (one lifetime); osteoporosis screening once every 2 calendar years; cervical cancer screening and related office visit 1 per calendar year; PSA test 1 per calendar year for subscriber and spouse; mammogram 1 per calendar year; lipid disorders screening every 5 calendar years; hepatitis B and C screening; lung cancer screening limited to adults 50-80, 1 per calendar year; ambulatory blood pressure monitoring for diagnostic confirmation; HIV screening and counseling; type 2 diabetes screening per guidance

See document for modality-specific colorectal screening intervals

Colorectal cancer screening modalities and intervals: Members age 45 through 75: fecal occult blood test 1 per calendar year; FIT 1 per calendar year; FIT-DNA 1 every 3 years; colonoscopy (including related services) 1 every 10 years (allows follow-up colonoscopy within one year after a non-invasive stool-based or direct visualization test); sigmoidoscopy 1 every 5 years; CT colonography 1 every 5 yearsAge 45 through 75

Reproductive and pregnancy-related services: Asymptomatic bacteriuria screening for pregnant women; Rh (D) incompatibility screening for pregnant women; iron deficiency anemia screening in pregnancy; screening and counseling for interpersonal and domestic violence; lactation support and counseling (5 visits per pregnancy); breast pump 1 per pregnancy (manual or electric); counseling and screening for HIV; contraceptive methods and management including female sterilizations, IUD insertion/removal, injections, implants, cervical cap, diaphragm, and covered prescription/OTC contraceptives when prescribed

Behavioral and counseling services: Alcohol misuse screening and behavioral counseling: 1 visit per calendar year for ages 6-18; unlimited for 18+; tobacco cessation counseling up to 8 visits per calendar year and tobacco cessation supplies up to a 180-day supply; behavioral counseling interventions for diet/activity and weight-related prevention (limit 26 visits/year for ages 6-18; 12 visits/year for 19+); interventions to prevent perinatal depression 12 visits/year for pregnant and postpartum women within 12 months of delivery

Includes obesity/BMI-related counseling limits

Preventive prescription drugs and supplies: Prescription preventive drugs must be filled as a prescription and submitted through the prescription drug card program. Covered items include aspirin 81 mg for adults 45-79 and for preeclampsia prevention in pregnancy; folic acid 0.4-0.8 mg for women; oral fluoride for children age 6 months-16 years when drinking water fluoride is insufficient; iron supplements for children ages 6-12 months at risk for anemia; statins for prevention of cardiovascular disease for adults 40-75 (includes lovastatin, pravastatin, rosuvastatin); HIV preexposure prophylaxis for persons at high risk

Brand vs generic rules apply: generics $0 copay for certain preventive drugs; brands pay normal benefit level unless documentation provided; bowel prep generics $0 copay; contraceptives Tier 1 & 2 paid at 100% (Tier 3 subject to cost-share)

Benefits other than those outlined in this document will not be covered as preventive or wellness benefits. This policy applies only when the service meets the plan's preventive definition and is performed in accordance with the member's benefit document. Services must be performed by a Participating Provider (Wyoming Choice Provider for Wyoming Choice Network products) or at an approved Health Fair; non‑participating/non‑network services are not eligible for preventive/wellness benefit coverage. Deductible and coinsurance are waived for covered preventive services when the above requirements are met.

Screening Ages & Coding Notes

Colorectal screening age range

Age range45 through 75

Included modalitiesFOBT and FIT: annual; FIT‑DNA: every 3 years; Colonoscopy: every 10 years (or follow‑up within 1 year after a positive non‑invasive test); Sigmoidoscopy: every 5 years; CT colonography: every 5 years

Cost‑sharingDeductible and coinsurance waived when performed by participating providers or health fair

Lung cancer screening age range

Age rangeAdults 50–80

Frequency1 per calendar year

Cost‑sharing

Provider Requirements & Billing Guidance

Note

Benefit Applicability — Confirm member coverage

Verify that the preventive care benefit applies to the member's specific plan and line of business before billing or providing services. Preventive services listed in the plan are applicable only when the member's benefit document or summary of benefits includes Preventive Care coverage (for example, USPSTF A/B recommended services, ACIP, HRSA, and Bright Futures).

Check the member's benefit document / summary of benefits for Preventive Care applicability
Benefits OTHER than those specifically outlined as preventive will not be covered as preventive or wellness benefits

Billing Rule

Brand vs Generic Requirement — Member pays difference unless documented

When a generic preventive drug is available, generics are covered at $0 copay. If a participant chooses a brand-name drug when a generic equivalent is available, the participant must pay the difference in cost between the brand and the generic unless documentation supports preventive use of the brand.

Definitions & Preventive Services Included

Preventive services — definitions and authoritative sources

Sources referencedU.S. Preventive Services Task Force (USPSTF) A/B recommendations, CDC ACIP, HRSA, and 'Bright Futures'

ApplicabilityCovered when the member's plan preventive definition includes those recommendations

Cost‑sharing rulePreventive services meeting these sources are covered with deductible and coinsurance waived when performed by participating providers or health fair

Plan limitationBenefits shown apply only to certain types and lines of business; refer to the member's benefit document for applicability

Provider/network requirementServices must be done by a Participating Provider (Wyoming Choice Provider for Wyoming Choice Network products) or Health Fair

This document lists recommended preventive screenings, immunizations, counseling, and supplies consistent with major authorities when those sources are included in the member's preventive definition: the U.S. Preventive Services Task Force (USPSTF) A/B recommendations, the CDC Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and 'Bright Futures'. These recommendations align with PPACA requirements and Wyoming law for comprehensive preventive and women's preventive services; applicability depends on the member's plan benefit language.