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 applicable Blue Cross Blue Shield - Wyoming plans and lines of business, and who may be eligible based on the member's benefit document and network participation.

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 through a Participating Provider or Health Fair to ensure deductible and coinsurance are waived and follow specified frequency limits and prior authorization rules (e.g., prior approval required for hospital-grade breast pumps).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

To age 6Covered well child care period

CDC-recommendedImmunizations covered

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CurrentBlue Cross Blue Shield - WyomingPolicy N/A

Preventive Care Benefits — Coverage Criteria

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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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

To age 6Covered well child care period

CDC-recommendedImmunizations covered

Colorectal screening age range

1/yrMammogram frequency

8/yrTobacco cessation visits

Preventive Service Coverage Criteria

Covered preventive services

Covered preventive services (deductible and coinsurance waived) when provided by a participating provider or health fair and applicable per the member's benefit document.

General coverage condition: Service is included in the preventive care list and falls within the member's plan preventive benefits; service is provided by a Participating Provider or Health Fair.

Included preventive services (selected examples): Well child visits per age-defined schedule; CDC-recommended immunizations; newborn screenings (PKU, congenital hypothyroidism, bilirubin); vision and hearing screening; developmental and autism screening through age 2; lead screening through age 6; oral health and fluoride varnish for children through age 6; routine adult preventive visits; cancer screenings (cervical, breast, colorectal, PSA); tobacco cessation counseling; alcohol misuse screening and counseling; diabetes screening in pregnancy; BRCA testing when family history indicates; lung cancer screening limited to ages 50-80; HIV screening and PrEP for high-risk persons; contraceptive methods and management; lactation support and breast pump (prior approval required for hospital-grade pumps).

Frequency limits and specifics: Specific frequency rules apply: well child visit counts by age groups (birth–12 months: 7 visits; 13–35 months: 4 visits; 36–72 months: 1/year); sensory screening vision and hearing up to once per calendar year through age 21; congenital and newborn screenings as listed; colorectal testing: FOBT or FIT 1/year, FIT‑DNA every 3 years, colonoscopy every 10 years OR sigmoidoscopy every 5 years; cervical cancer screening 1/year; PSA 1/year (subscriber and spouse only); mammogram 1/year; HPV testing at age 30 every 3 years; osteoporosis screening once every 2 calendar years; lung cancer screening limited to adults 50–80, 1/year; alcohol misuse and behavioral counseling frequency limits; tobacco cessation counseling up to 8 visits per calendar year and medication limits as specified.

Benefits other than those outlined in this policy will not be covered as a preventive or wellness benefit. Coverage described here applies only when the member’s benefit document includes preventive services per USPSTF (A/B), ACIP, HRSA, or Bright Futures and when the service is provided by a Participating Provider (or at an approved Health Fair). Non‑participating / non‑network services are not covered as preventive care.

Age-Based Screening Thresholds & Coding Notes

Age-based screening thresholds

Well child care periodWell child visits to participant's 6th birthday (age-based visit schedule: birth–12 months: 7 visits; 13–35 months: 4 visits; 36–72 months: annual)

Colorectal cancer screening agesAdults age 45 through 75; options include FOBT or FIT annually, FIT‑DNA every 3 years, colonoscopy every 10 years, or sigmoidoscopy every 5 years

Abdominal aortic aneurysm (AAA) screeningAdult aortic aneurysm screening for male participants ages 65–75 — lifetime maximum of 1 screening

Lung cancer screening age rangeScreening limited to adults ages 50–80 — 1 per calendar year

Cervical and HPV screeningCervical cancer screening and related office visit: 1 per calendar year; HPV testing at age 30 every 3 years

Mammography frequencyMammogram screenings: 1 per calendar year

Provider Requirements, Prior Authorization, and Billing Rules

Billing Rule

Network Requirement

Services must be performed by a Participating Provider (Wyoming Choice Provider for Wyoming Choice Network products) or at an authorized Health Fair. Non-participating / non-network services are not covered except as allowed by the member's benefit document or state law. Verify network status prior to scheduling to avoid claim denials or balance billing to the member.

Participating Provider or authorized Health Fair required
Non-participating services not covered (unless benefit document/state law allows)

Prior Authorization

Prior Authorization Required for Hospital‑Grade Breast Pumps

Prior approval is required for hospital‑grade breast pumps. Providers must obtain prior authorization before dispensing or billing for hospital‑grade electric breast pumps to avoid denial of preventive benefit coverage.

Policy Background

This document describes the preventive services for which the plan waives deductible and coinsurance when the service is within the member’s preventive benefit. It includes routine pediatric well‑child care through the participant’s sixth birthday, CDC‑recommended immunizations, newborn screenings, sensory (vision/hearing) and developmental screenings, age‑based cancer screenings (for example colorectal, cervical, and breast), tobacco and alcohol misuse counseling, certain prenatal and pregnancy‑related screenings, selected preventive medications and contraceptive services, and other services that meet federal preventive care criteria. Coverage follows recommendations from the U.S. Preventive Services Task Force (A and B), ACIP, HRSA women’s preventive services, and Bright Futures where specified.

Definitions and Covered Sources

Preventive services definitions

Definition of preventive servicesServices recommended by USPSTF (A/B), ACIP, HRSA, and Bright Futures that are covered as preventive care under applicable benefits

Coverage conditionPreventive services are covered with deductible and coinsurance waived when provided by a Participating Provider (or Health Fair) and applicable per the member's benefit document

ImmunizationsImmunizations as recommended by the CDC/ACIP are covered preventive services

Women's preventive servicesHRSA–recommended women's preventive services (including contraceptive methods & management, lactation support, and related screening) are included when applicable

Bright Futures and pediatric servicesBright Futures–recommended well‑child and developmental screenings (including newborn screenings, vision, hearing, lead, and autism/developmental screening through age 2) are covered

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

SourceLink

On This Page

Hospital‑grade breast pumps: Prior authorization required
Confirm approval before dispensing to prevent claim denials

Billing Rule

Screening Frequency Limits and Billing Implications

Preventive screening services have specific frequency limits. Bill and document the service date and screening type accurately; providing a screening more frequently than the stated interval may result in non‑coverage as a preventive service and possible member cost responsibility.

Fecal occult blood test / FIT: 1 per calendar year
FIT‑DNA: 1 every 3 years
Colonoscopy: 1 every 10 years (or Sigmoidoscopy 1 every 5 years)
Cervical cancer screening and related office visit: 1 per calendar year
PSA test: 1 per calendar year (subscriber and spouse only)
Mammogram: 1 per calendar year
Lung cancer screening (age 50–80): 1 per calendar year
Behavioral counseling visit limits: up to 26 per year (ages 6–18) and 12 per year (19+)
Lipid disorders screening: once every 5 calendar years

Note

Generic‑First Expectation and Member Cost Responsibility

Prescription preventive medications must be filled with a prescription and submitted through the prescription drug card program. When a generic equivalent exists, generic drugs are expected to be used first. If a brand drug is chosen when a generic is available, the member must pay the difference in cost between the brand and the generic unless documentation supports brand use.

Preventive prescription drugs must be processed through the prescription drug benefit
Generics expected first; $0 copay for generics where noted
If member selects brand when generic exists, member pays cost difference
Examples noted as preventive: aspirin 81 mg (Adults 45–79), folic acid 0.4–0.8 mg (women), oral fluoride for children, iron supplements for infants, nicotine replacement therapy limits and supplies

Documentation Required

Prescription Drug Documentation Required for Brand Preventive Drugs

For brand preventive drugs to be processed at preventive benefit levels, providers must submit documentation demonstrating medical necessity for the brand over the generic and that the drug is being prescribed for preventive use. Without this documentation, brands will be paid at the normal (non‑preventive) benefit level.

Documentation must show: (1) prescribed for preventive use, AND (2) specific medical rationale for brand over generic
If documentation is not provided, brand drugs will be subject to normal benefit/copay