Preventive Care Benefits — Coverage Criteria
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Defines preventive care services covered (deductible and coinsurance waived) under certain Blue Cross Blue Shield - Wyoming lines of business when provided in-network or at approved health fairs; applies to participants/members as described by service categories and age ranges.
No material clinical or coverage changes in this revision.
Preventive Services Coverage Criteria
General coverage stance
Covered preventive services (deductible and coinsurance waived) when provided in-network by eligible providers and when included in the plan's preventive definition.
See member benefit document for line-of-business applicability.
Well child care (birth to 6th birthday)
Covered when ALL of the following are met
Applies to members through the participant's 6th birthday for the pediatric-specific items listed.
Adolescent and adult preventive services
Covered services with specified age and frequency limits (examples listed; refer to the plan document for complete details).
See plan document for the full list of adolescent and adult preventive services and any additional age- or pregnancy-specific items (e.g., prenatal screenings).
Behavioral and prescription preventive interventions
Covered counseling and prescription preventive therapies with specified limits.
Includes counseling for diet/physical activity, healthy weight gain in pregnancy, and midlife women weight maintenance as listed in the plan.
All prescription preventive drugs must be filled as a prescription and submitted through the prescription drug card program; brand vs generic rules apply as stated.
Benefits described in this policy reflect the preventive and wellness services that meet PPACA criteria and applicable clinical authorities. Benefits other than those outlined below will not be covered as a preventive or wellness benefit.
Preventive services must be provided by an eligible in-network source to receive preventive benefit coverage. Nonparticipating/non-network services are not covered as preventive benefits; services must be performed by a Participating, In-Network, or Health Fair Provider for deductible and coinsurance to be waived.
Coding and Screening Age Guidance
| No codes listed |
Provider Requirements and Actions
Prior authorization — verify per benefit
Verify prior authorization requirements based on the member's benefit document and authorization rules for the specific service; the preventive services listing does not enumerate procedures requiring prior authorization. Providers should check the member's plan for any imaging, procedural, or other service-specific authorization requirements before scheduling.
- Document does not list specific procedures requiring prior auth; verify per benefit.
- Check benefit document and prior authorization rules for imaging, procedures, or other services as applicable.
Step therapy / drug program note
Prescription preventive drugs must be obtained through the member's prescription drug program and are subject to the plan's normal drug benefit rules (e.g., step therapy, quantity limits, brand vs. generic cost differentials).
- Prescription drugs must be filled as a prescription and submitted through the prescription drug card program.
- Brand drugs will pay at the normal benefit level unless paperwork demonstrates preventive use and medical need for the brand.
Benefit verification — confirm applicability
Confirm whether the preventive care benefit applies for the member's line of business and whether the specific service falls under the plan's preventive definitions (USPSTF A/B, ACIP, HRSA, Bright Futures) by referring to the member's benefit document.
- Refer to the Preventive Care section in the member's benefit document for line-of-business applicability.
- Ensure the service is included in the plan's preventive definition (USPSTF A/B, ACIP, HRSA, Bright Futures) to qualify for waived cost-sharing.
Network requirement — use in‑network/participating providers
Perform preventive services only through a Participating, In‑Network, or approved Health Fair Provider; preventive services provided by nonparticipating or non‑network providers are not covered.
- Services must be done by a Participating, In‑Network, or Health Fair Provider.
- Nonparticipating/non‑network services are not covered as preventive benefits.
Background and Guiding Recommendations
This policy references the U.S. Preventive Services Task Force (USPSTF) A/B recommendations, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration (HRSA), and the Bright Futures guidelines as the clinical authorities used to define covered preventive services. When a member’s preventive care definition includes services recommended by these organizations, those services are eligible for coverage with waived deductible and coinsurance as outlined in this document.
Definitions and Scope
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