CurrentBlue Cross Blue Shield - WyomingPolicy N/A

Preventive Care Benefits — Coverage Criteria

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Defines covered preventive and wellness services, screenings, immunizations, and related prescription preventive drugs for eligible members and specifies that services must be delivered by participating providers; applicability varies by line of business and member benefit documents.

Policy Summary

PayerBlue Cross Blue Shield - Wyoming

PolicyPreventive Care Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide preventive services only when performed by participating providers or health fairs to qualify for waived deductible and coinsurance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ScheduleWell-child visits through age 6

45-75Colorectal age range

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CurrentBlue Cross Blue Shield - WyomingPolicy N/A

Preventive Care Benefits — Coverage Criteria

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Wyoming policy alerts

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 change

Effective DateN/A

Next Review DateN/A

Key ActionProvide preventive services only when performed by participating providers or health fairs to qualify for waived deductible and coinsurance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ScheduleWell-child visits through age 6

45-75Colorectal age range

Covered Preventive Services & Limitations

Covered Preventive Services

Covered preventive services and frequencies (Deductible and coinsurance waived) when benefits apply and services are performed by participating providers:

General applicability: Benefit applies only where preventive care benefits are included in the member's benefit document and for eligible lines of business; services must be provided by participating providers or health fairs.

Well-child care: newborn blood screening; prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum; scheduled well-child visits (birth–12 months: 7 visits; 13–35 months: 4 visits; 36–72 months: 1 visit per calendar year); immunizations as recommended by the CDC; congenital hypothyroidism screening under age 1; hearing screening (newborn and sensory screening through age 21 as specified); PKU screening once per lifetime (ages 0–1); sickle cell screening up to age 1; hematocrit/hemoglobin through age 1; lead screening through age 6; developmental and autism screening through age 2; oral health screening; fluoride varnish from birth up to age 6; newborn bilirubin screening.

Age-based preventive services (children through adults): Age-based and routine screenings: sensory vision and hearing screening up to age 21 (vision 1 per calendar year; hearing 1 per calendar year in addition to newborn screening); tuberculin test; behavioral/social/emotional screening; routine physical examination office visits for participants age 6 and older (males 1 per calendar year); depression and other screenings as part of visits; adult aortic aneurysm screening for males 65–75 (lifetime maximum of 1); alcohol misuse screening and behavioral counseling (1 visit/year for ages 6–18; unlimited for 18+); asymptomatic bacteriuria screening in pregnant women; hepatitis B and C screening; Rh(D) incompatibility and iron deficiency anemia screening in pregnancy; STD screening and counseling per ages indicated; diabetes screening in pregnancy (24–28 weeks); HPV testing at age 30 every 3 years; screening and counseling for interpersonal and domestic violence; lactation support (5 visits per pregnancy) and 1 breast pump per pregnancy; counseling and screening for HIV; type 2 diabetes screening; immunizations per CDC.

Cancer screenings: cervical cancer screening and related office visit (1 per calendar year); mammogram screening (1 per calendar year); colorectal cancer screening for members age 45–75 with specified frequencies (FOBT/FIT 1 per year; FIT‑DNA 1 every 3 years; colonoscopy 1 every 10 years with allowance for follow-up colonoscopy within 1 year after a non‑invasive stool‑based or direct visualization test; sigmoidoscopy 1 every 5 years; CT colonography 1 every 5 years); PSA test 1 per calendar year for subscriber and spouse only; BRCA testing and genetic counseling when family history indicates increased risk.

Behavioral and risk-reduction counseling: Behavioral and risk‑reduction counseling: tobacco cessation counseling (8 visits per calendar year); behavioral counseling interventions to promote healthy diet and physical activity and other listed interventions (limit 26 visits/year for ages 6–18 and 12 visits/year for 19+); interventions to prevent perinatal depression (12 visits/year for pregnant women or within 12 months postpartum); exercise or physical therapy for community‑dwelling adults 65+ at increased fall risk; HIV pre‑exposure prophylaxis for persons at high risk.

Preventive diagnostics and screenings for adults: Preventive diagnostics and screening procedures for adults: ambulatory blood pressure monitoring (ABPM) for diagnostic confirmation of high blood pressure in adults; screening for latent tuberculosis infection; osteoporosis screening once every 2 calendar years; adult aortic aneurysm screening as noted; hepatitis C screening; screening for lung cancer limited to adults 50–80 (1 per calendar year); screening for latent TB; other diagnostic screenings as specified.

Preventive medications and supplies: prescription preventive drugs must be filled and submitted through the prescription drug card program; aspirin 81 mg limited to adults 45–79 and for preeclampsia prevention in pregnancy; folic acid (non‑prenatal) 0.4–0.8 mg for women; oral fluoride for children age 6 months–16 years when drinking water lacks sufficient fluoride; iron supplements for children 6–12 months at risk; tobacco cessation medications (NRT and non‑NRT) with supply limits including up to a 180‑day supply and coverage of OTC and prescription NRT forms; contraceptives (Tier 1 & 2 paid at 100%; Tier 3 subject to copay/coinsurance) and other FDA‑approved methods as described; bowel prep medications for preventive colonoscopy ($0 copay for generics; brands at normal benefit level); statins for primary prevention ages 40–75 (includes lovastatin, pravastatin, rosuvastatin); medications for primary breast cancer risk reduction in women ≥35; preexposure prophylaxis for HIV; brand drug cost differential applies when generic available.

Benefits other than those outlined in this document will not be covered as preventive or wellness benefits. Coverage as a preventive or wellness service is limited to the services and frequencies described in this policy and applies only when the member’s benefit document includes preventive care benefits.

Screening Frequencies, Visit Counts, and Coding-relevant Limits

Well‑child visit schedule (birth through 6 years)

Newborn through 12 months7 well-child visits

13 through 35 months4 well-child visits

36 through 72 months1 well-child visit per calendar year

Colorectal cancer screening frequencies (ages 45–75)

FOBT / FITOne test per calendar year

FIT‑DNA (stool DNA)One test every 3 years

ColonoscopyOne every 10 years; follow‑up colonoscopy allowed within 1 year after a non‑invasive stool‑based or direct visualization test

Provider Requirements, Prior Auth, and Billing Notes

Documentation Required

Services Must Be Performed by a Participating Provider or Health Fair

Services must be performed by a Participating Provider (Wyoming Choice Provider for Wyoming Choice Network products) or at an approved Health Fair to be covered as preventive benefits. If services are provided by non-participating or non-network providers, they are not covered as preventive or wellness benefits under this plan.

Participating Provider = in-network clinicians/facilities (Wyoming Choice for Wyoming Choice Network products)
Health Fair = approved events recognized by the plan
Non-participating/non-network services = not covered as preventive/wellness benefits

Denial Risk

Provider Network Requirement — Non-Participating Providers Not Covered as Preventive

Non-participating or non-network providers' services are excluded from preventive/wellness coverage. Claims submitted for preventive services performed by out-of-network providers may be processed under the member's standard medical benefits (subject to applicable deductibles, coinsurance, and network rules) but will not be paid as preventive benefits with deductible/coinsurance waived.

Policy Background and Guideline References

This policy describes preventive services that meet requirements of the Patient Protection & Affordable Care Act (PPACA) and, where included in the member’s benefit definition, services recommended by the U.S. Preventive Services Task Force (USPSTF) A and B recommendations, the CDC’s Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and Bright Futures. It also notes that these benefits satisfy Wyoming’s definition of comprehensive adult wellness benefits and that applicability may vary by line of business and the member’s benefit document.

Definitions Relevant to Preventive Care Benefits

Preventive Care Benefits — definition and applicability

DefinitionServices that meet PPACA preventive/wellness criteria when included in the member's benefit definition—specifically USPSTF A/B recommendations, ACIP immunization guidance, HRSA women's services, and Bright Futures

Coverage conditionBenefits apply only where preventive care is included in the member's benefit document and for eligible lines of business

Provider requirementServices must be performed by a Participating Provider (Wyoming Choice Provider for Wyoming Choice Network products) or Health Fair to be covered

ExclusionServices other than those outlined in this policy will not be covered as preventive or wellness benefits