Preventive Care Benefits — Coverage Criteria
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Defines covered preventive and wellness services (screenings, immunizations, counseling, and selected preventive medications and supplies) for eligible members when the member's Preventive Care definition includes USPSTF (A/B), ACIP, HRSA, and Bright Futures; services must be delivered by participating/in-network or health fair providers to be covered.
No material clinical or coverage changes in this revision.
Covered Preventive Services & Limits
Preventive Services Covered
Covered preventive services and limits when delivered as preventive care by in-network/participating providers:
Deductible and coinsurance waived for covered preventive services
Includes the well-child items listed above
Office visits may include listed screenings and counseling
Many services limited by frequency or population as specified
Follow-up colonoscopy allowed within 1 year after positive non-invasive or visualization tests
Breast pump covered 1 per pregnancy; lactation support 5 visits per pregnancy
Prescription preventive drugs must be filled through the prescription drug benefit; generics may have $0 copay; if participant chooses brand when a generic exists, participant pays the difference; bowel prep generics $0 copay
These benefits meet the criteria outlined in the Patient Protection and Affordable Care Act (PPACA) for wellness and preventive benefits. Benefits OTHER than those outlined below will not be covered as a preventive or wellness benefit. Refer to the member's benefit document for applicability and any plan‑specific limitations.
To qualify for coverage as a preventive benefit under this policy, services must be provided by a Participating, In‑Network, or Health Fair Provider. Nonparticipating / non‑network services are not covered as preventive benefits.
The document does not list a separate catalog of ‘not medically necessary’ procedures; instead, coverage as a preventive or wellness benefit is limited to the specific services and recommendations described in this policy and the member’s benefit document. Services not outlined here or in the member’s Preventive Care benefit are not covered as preventive benefits.
Codes, Age Thresholds & Screening Frequencies
| Document provides no explicit CPT/HCPCS/ICD-10/NDC codes; lists services and frequencies only. |
Provider Responsibilities, Prior Auth & Cost-sharing
Network Requirement: In‑Network Providers Only
Services must be performed by a Participating, In‑Network, or Health Fair Provider. Nonparticipating / non‑network services are not covered and may be denied when billed as preventive care.
- Non‑network services are not eligible for preventive benefit coverage.
- Verify provider network status prior to scheduling preventive services.
Prior Authorization / Coding Note
Prior authorization is not specified as a blanket requirement for the preventive services described; however, members’ benefit documents and plan rules govern coverage and any specific authorization or coding requirements. Providers should submit appropriate documentation to demonstrate that services meet the preventive benefit criteria in the member’s plan.
- No universal procedure codes or blanket prior authorization listed in this section — check member benefit document for plan‑specific rules.
- Document medical necessity or preventive indication when submitting claims to ensure deductible/coinsurance waiver is applied correctly.
Benefit Applicability
Preventive services described are applicable only when the member’s benefit document includes the referenced federal recommendations (USPSTF A/B, ACIP, HRSA, Bright Futures). These benefits meet PPACA preventive/wellness criteria; services other than those listed are not covered as preventive benefits.
- Coverage applies only for plans that include the specified federal preventive recommendations.
- Other services not explicitly listed will not be paid as preventive/wellness benefits and may be subject to regular cost‑sharing.
Medication Selection and Cost‑Sharing
For preventive prescription drugs: generics approved as preventive are covered at $0 copay when filled as a prescription and submitted through the plan’s prescription drug program. If a member elects a brand when a generic exists, the member must pay the difference between the brand and generic cost unless documentation is provided showing medical necessity for the brand. Certain contraceptives (Tier 1 & 2) are paid at 100%; Tier 3 is subject to copay/coinsurance per the drug benefit.
- Generics for preventive indications: $0 copay when filled by prescription and billed through the drug program.
- Brands: member pays the difference if a generic is available unless paperwork documents preventive use and medical need for the brand.
- Bowel prep meds for preventive colonoscopy: generics $0 copay; brands pay at normal benefit level.
- Contraceptives: Tier 1 & 2 = 100% coverage; Tier 3 subject to regular cost sharing.
Policy Background & Evidence Sources
This policy lists preventive services and recommended frequencies drawn from authoritative sources used to define covered preventive benefits under PPACA: the U.S. Preventive Services Task Force (USPSTF) (A and B recommendations), the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and Bright Futures. These evidence‑based sources inform the categories and frequency limits (for example, childhood well visits, immunizations per CDC/ACIP schedules, and adult age‑based screening intervals) applied when the member’s Preventive Care definition includes these recommendations.
Key Definitions
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