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 eligible members and specifies provider/network requirements for Blue Cross Blue Shield - Wyoming products. Applicable services follow USPSTF (A/B), ACIP, HRSA, and Bright Futures recommendations where indicated.

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 DateJuly 2025

Key ActionVerify member benefits and ensure preventive services are provided by a participating (Wyoming Choice) provider to qualify for waived deductible and coinsurance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Deductible waivedcoverage stance for listed preventive services

Well Child to 6th bdaypediatric well care coverage

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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 changes

Effective DateN/A

Next Review DateJuly 2025

Key ActionVerify member benefits and ensure preventive services are provided by a participating (Wyoming Choice) provider to qualify for waived deductible and coinsurance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Deductible waivedcoverage stance for listed preventive services

Well Child to 6th bdaypediatric well care coverage

Covered Preventive Services & General Rules

Covered preventive services

Covered preventive services (deductible and coinsurance waived) when provided by an in-network provider and applicable under the member's benefit:

Pediatric well-child care: Well child care through the participant's 6th birthday including: newborn blood screening; prophylactic ocular topical medication for prevention of gonococcal ophthalmia neonatorum; visit schedule (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 loss screening up to 1 month of age; phenylketonuria (PKU) screening once in lifetime ages 0–1; sickle cell disease screening up to age 1; iron deficiency anemia prevention for at‑risk children 6–12 months; hematocrit or 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 (applied by primary care clinicians); newborn bilirubin screening.age-based per item

See chunk 1 for itemized services

Child and adolescent screenings and routine care: Sensory vision screening (1 per calendar year) through age 21; sensory hearing screening (1 per calendar year in addition to newborn/early screens) through age 21; tuberculin test; behavioral/social/emotional screening; routine physical examination (office visit) for participants age 6 and older (males 1 per calendar year); well‑woman preventive visits as medically appropriate, which may include depression screening, urinary incontinence screening, skin cancer evaluation, and education/brief counseling to prevent tobacco initiation among school‑aged children and adolescents.age-based

See chunks 1-2

Adult preventive screenings and services: Adult preventive services including: aortic aneurysm screening (male participants age 65–75, lifetime maximum 1 screening); alcohol misuse screening and behavioral counseling (1 visit/yr for participants 6–18; unlimited for 18+); asymptomatic bacteriuria screening (pregnant women only); hepatitis B screening; Rh (D) incompatibility screening (pregnant women only); osteoporosis screening once every 2 calendar years; iron deficiency anemia screening (pregnant women only); STD screening per population (chlamydia, gonorrhea, syphilis as specified); counseling for STIs; diabetes screening in pregnant women (24–28 weeks gestation); HPV testing at age 30 every 3 years; screening and counseling for interpersonal and domestic violence; lactation support & counseling (5 visits per pregnancy); breast pump (1 per pregnancy); HIV screening and diagnostic testing for at‑risk/pregnant persons; type 2 diabetes mellitus screening; immunizations per CDC recommendations.age/population-based

See chunk 2

Cancer screening: Cervical cancer screening and related office visit (1 per calendar year); mammogram screenings (1 per calendar year); colorectal cancer screening for members age 45–75 with modality‑specific intervals: 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, with allowance for a follow‑up colonoscopy within one year after a noninvasive positive stool‑based or direct visualization test), sigmoidoscopy including related services (1 every 5 years), and CT colonography (1 every 5 years); PSA test (1 per calendar year for subscriber and spouse only).age and modality-specific

See chunks 3-4

Behavioral counseling and preventive interventions: Tobacco cessation counseling (8 visits per calendar year) and tobacco cessation medications/supplies (including up to 180 day supply and NRT options); behavioral counseling interventions for nutrition/weight and related indications (limit 26 visits/yr for ages 6–18; 12 visits/yr for 19+); interventions to prevent perinatal depression (12 visits/yr for pregnant or within 12 months postpartum); HIV preexposure prophylaxis for persons at high risk; ambulatory blood pressure monitoring (ABPM) for diagnostic confirmation of hypertension; lung cancer screening limited to adults age 50–80, 1 per calendar year.visit limits and age-based

See chunks 4-5

Preventive prescription drugs and supplies: Covered preventive medications and supplies when filled through the prescription drug program: aspirin 81 mg (adults 45–79 and for prevention of preeclampsia in pregnancy); folic acid 0.4–0.8 mg for women; oral fluoride (children 6 months–16 years when drinking water lacks sufficient fluoride); iron supplements for children 6–12 months at risk for anemia; tobacco cessation medications (including non‑nicotine options and OTC or prescription NRT); contraceptives to prevent conception (tiered coverage with Tier 1 & 2 at 100%, Tier 3 subject to copay/coinsurance; includes oral, patch, ring, sponge, condoms, spermicide, emergency contraception, and other FDA‑approved methods prescribed by a provider); medications for risk reduction of primary breast cancer (generics $0 copay; brands at normal benefit level unless paperwork documents preventive use and medical rationale); bowel prep medications for preventive colonoscopy (generics $0 copay; brands at normal benefit level); statins for primary prevention of cardiovascular disease for adults 40–75 including lovastatin, pravastatin, and rosuvastatin; HIV PrEP for persons at high risk.population-based or supply limits

See chunks 4-5

Benefits OTHER than those specifically listed in this policy will not be covered as a preventive or wellness benefit. The policy implements preventive care coverage consistent with the Patient Protection and Affordable Care Act (PPACA) and applicable state definitions; only services enumerated here (and any additional services that meet the referenced federal/state criteria when included in the member's benefit document) qualify for preventive/wellness benefit treatment such as waiver of deductible and coinsurance.

To receive preventive/wellness benefit treatment, services must be furnished 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 covered as preventive benefits; members and providers should confirm network status before scheduling preventive services to avoid denial of preventive benefit application.

Screening Age Ranges & Key Codes

Colorectal screening (age range and key details)

Age range45-75 years

Modalities coveredFOBT/FIT annually; FIT‑DNA every 3 years; colonoscopy every 10 years (follow-up colonoscopy within 1 year after positive noninvasive test allowed); sigmoidoscopy every 5 years; CT colonography every 5 years

Cost sharingDeductible and coinsurance waived when provided by an in‑network provider and applicable under the member's benefit

Lung cancer screening (age range and frequency)

Age range50-80 years

FrequencyScreening limited to adults 50-80; 1 per calendar year

Provider Requirements, Billing & Authorization

Documentation Required

Benefit Applicability Verification

Verify benefit applicability for each member before providing preventive services. Preventive care benefits apply only when specified in the member's benefit document and may vary by product, line of business, or plan design (for example, Wyoming Choice Network products). Confirm the member's coverage for preventive services (including which services qualify under PPACA/USPSTF/ACIP/HRSA/Bright Futures criteria) and whether the provider is in-network or the service is delivered at an approved Health Fair. Services performed by non-participating or non-network providers are not eligible for the preventive benefit.

Confirm preventive benefit is included in the member's specific plan and line of business.
Verify in-network provider status (Participating Provider or Wyoming Choice Provider for Wyoming Choice Network products) or approved Health Fair.
Check applicable preventive service lists (USPSTF A/B, ACIP, HRSA, Bright Futures) per the member's plan.

Definitions Relevant to Preventive Benefits

Definition — Preventive Care Benefits

DefinitionPreventive Care Benefits are services recommended by the U.S. Preventive Services Task Force (USPSTF) rated A or B, the CDC's Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and 'Bright Futures' when the member's benefit document includes those recommendations.

ApplicabilityBenefits apply only for certain types and lines of business; refer to the member's benefit document to confirm applicability.

Provider/network requirementServices 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 covered as preventive benefits.

Policy Background & Scope

This policy aligns covered preventive services with federal recommendations and recognized authorities. When the member's benefit document incorporates the U.S. Preventive Services Task Force (USPSTF) recommendations rated A or B, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and Bright Futures, those services are included as preventive benefits under this policy. These covered services meet PPACA wellness and preventive benefit criteria and also satisfy the definition of comprehensive adult wellness benefits under the Wyoming Health Insurance Code.