Blue Cross Blue Shield WY Preventive Care Coverage

Covered Preventive Services & Limits

Preventive Services Covered

Covered preventive services and limits when delivered as preventive care by in-network/participating providers:

Pediatric well-child care up to age 6: Newborn blood screening; prophylactic ocular topical medication for prevention of 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; newborn bilirubin; PKU screening once per lifetime ages 0–1; sickle cell screening up to age 1; congenital hypothyroidism screening under age 1; hearing screening up to 1 month of age; hematocrit or hemoglobin through age 1; iron deficiency anemia prevention for children at risk 6–12 months; 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)age-based

Deductible and coinsurance waived for covered preventive services

Child and adolescent screenings through age 21: Sensory screening vision and hearing — 1 per calendar year (hearing in addition to newborn/specific screens) ; tuberculin test; behavioral/social/emotional screeningage-based up to 21

Includes the well-child items listed above

Routine preventive services for participants age 6 and older: Routine physical examination (office visit) — males 1 per calendar year; well-woman preventive care visits as medically appropriate; depression screening; screening for urinary incontinence; skin cancer evaluation; counseling/brief intervention to prevent initiation of tobacco use among school-aged children and adolescents; immunizations per CDCage 6+

Office visits may include listed screenings and counseling

Adult preventive screenings and condition-specific services: Adult aortic aneurysm screening — males 65–75 (lifetime maximum 1); alcohol misuse screening and behavioral counseling intervention — 1 visit/yr for ages 6–18 and unlimited for 18+; asymptomatic bacteriuria screening in pregnancy; hepatitis B and C screening; Rh(D) incompatibility and iron deficiency anemia screening in pregnancy; osteoporosis screening once every 2 calendar years; diabetes screening in pregnancy (24–28 weeks); HPV testing starting 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; counseling and screening for HIV; contraceptive methods & management (medical) including sterilizations, IUD insertion/removal, injections, implants, cervical cap, diaphragm; diagnostic HIV screening for at-risk and pregnant women; type 2 diabetes screening; ambulatory blood pressure monitoring for diagnostic confirmation of high blood pressure in adults; latent TB infection screening; interventions to prevent perinatal depression — 12 visits/yr for pregnant or postpartum up to 12 monthsage and condition specific

Many services limited by frequency or population as specified

Colorectal cancer screening options (ages 45–75): 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 (allow follow-up colonoscopy performed within 1 year after a non-invasive stool-based screening test or direct visualization test); sigmoidoscopy (including related services) — 1 every 5 years; CT colonography — 1 every 5 yearsage 45–75

Follow-up colonoscopy allowed within 1 year after positive non-invasive or visualization tests

Cervical, breast, prostate and lung cancer screening: Cervical cancer screening and related office visit — 1 per calendar year; mammogram screenings — 1 per calendar year; PSA test — 1 per calendar year for subscriber and spouse only; lung cancer screening — adults 50–80, 1 per calendar yearage and relationship specific

Breast pump covered 1 per pregnancy; lactation support 5 visits per pregnancy

Behavioral counseling and preventive medications: Tobacco cessation counseling — 8 visits per calendar year and tobacco cessation medication supply up to 180 days (includes non-nicotine therapies, OTC and prescription nicotine replacement therapies); behavioral counseling interventions — limit 26 visits/year for ages 6–18 and 12 visits/year for ages 19+ (for diet/physical activity, pregnancy weight management, midlife women weight maintenance); aspirin 81 mg — adults 45–79 and for prevention of preeclampsia in pregnant women; folic acid 0.4–0.8 mg — women only; oral fluoride for children 6 months–16 years when water fluoride insufficient; iron supplements for children 6–12 months at risk for anemia; statin therapy for prevention of cardiovascular disease — adults 40–75; HIV preexposure prophylaxis coveredvisit limits and age ranges

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

Preventive services (no codes listed)mixed

Document provides no explicit CPT/HCPCS/ICD-10/NDC codes; lists services and frequencies only.

Age-based screening thresholds

Colorectal cancer screeningAges 45–75: FOBT or FIT annually; FIT‑DNA every 3 years; colonoscopy every 10 years (allow follow‑up colonoscopy within 1 year after a positive non‑invasive or visualization test); sigmoidoscopy every 5 years; CT colonography every 5 years.

Breast cancer screening (mammogram)1 per calendar year.

Lung cancer screeningAdults age 50–80: low‑dose CT screening, 1 per calendar year.

Abdominal aortic aneurysm (AAA) screeningMale participants ages 65–75: lifetime maximum of 1 screening.

Cervical cancer screeningCervical cancer screening and related office visit: 1 per calendar year.

PSA testingPSA test: 1 per calendar year for subscriber and spouse only.

Provider Responsibilities, Prior Auth & Cost-sharing

Documentation Required

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

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.

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

Preventive Care Benefits — definition & scope

DefinitionPreventive Care Benefits: services that meet PPACA preventive/wellness criteria and recommendations from USPSTF (A/B), ACIP, HRSA, and Bright Futures; deductible and coinsurance waived when delivered by Participating, In‑Network, or Health Fair providers.

ApplicabilityBenefits illustrated are only applicable for certain types and lines of business; refer to the member's Preventive Care definition in the benefit document.

Provider/network requirementServices must be provided by a Participating, In‑Network, or Health Fair Provider; nonparticipating/non‑network services are not covered as preventive benefits.

Coverage scopeIncludes evidence‑based services such as well‑child visits, immunizations per CDC, age‑based adult screenings, counseling interventions, and selected preventive medications and supplies as outlined in the policy.

OpenPayer

Preventive Care Benefits — Coverage Criteria

Covered Preventive Services & Limits

Codes, Age Thresholds & Screening Frequencies

Provider Responsibilities, Prior Auth & Cost-sharing

Policy Background & Evidence Sources

Key Definitions