CurrentEmblemHealthPolicy N/A

EmblemHealth Preventive Care Services Benefit

Defines preventive care services covered under EmblemHealth preventive care benefit (per PPACA/USPSTF/ACIP/HRSA guidance), member cost-sharing rules for non-grandfathered and grandfathered plans, included screenings, counseling, immunizations, breastfeeding equipment, limits, exclusions, and extensive lists of procedure and diagnosis codes with frequencies and age ranges. This is part 1 of 2 of the full policy.

Policy Summary

PayerEmblemHealth

PolicyEmblemHealth Preventive Care Services Benefit

Policy CodePolicy N/A

Change TypeMultiple code additions/updates and vaccine/supply updates (see revision history)

Effective Date

Next Review Date

Key ActionProviders must report preventive versus diagnostic intent appropriately and follow coding, prior authorization and billing guidance in the policy (e.g., append Z29.81 for PrEP visits on/after 10/01/2023).

SourceLink

POLICY UPDATE CHANGES

Multiple ICD-10 codes deleted/added with effective dates (e.g., E66.8 deleted effective 10/1/2024; E66.811, E66.812, E66.813, E66.89 added effective 10/1/2024).

Breast pump supplies codes updated with effective dates (A4281-A4288 noted effective 1/1/2023 and new code effective dates 1/1/2024 and 10/1/2025).

Colorectal cancer screening new lab codes and effective dates added (0464U effective 9/01/2025; 0537U effective 1/1/2026).

Added HCPCS code A4288 to Breast Pump Supplies effective 10/1/2025.

Included COVID vaccine 91323 effective 8/27/2025.

2025-2026 Influenza vaccine updates and additions including codes 0455U and 0537U added.

Clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Counseling Services and Well Child Visits.

Added Cologuard Plus Lab Test CPT 0464U to Colorectal Cancer Screening effective 9/1/2025.

Updates to HPV screening codes effective 1/1/2025: addition of CPT 87626 and deletion of CPT 0500T.

Added PrEP Counseling and Administration Services codes GO011, GO012, GO013 and J0739; added ICD-10 Z29.81 (effective 1/1/2024).

Added RSV vaccine administration codes 96380 and 96381 effective 10/6/2023.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Summary

This policy implements the PPACA preventive services requirements by covering items and services recommended with an A or B rating by the US Preventive Services Task Force (USPSTF), routine immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), and evidence-informed pediatric preventive care in HRSA/AAP Bright Futures guidelines. Non-grandfathered plans must cover these preventive services when obtained in-network with no member cost-sharing, while grandfathered plans are not required to waive cost sharing and may exclude or limit services. Covered categories at a high level include preventive screenings and well visits, immunizations and vaccine administration, preventive counseling and behavioral interventions, and breastfeeding support including personal-use electric breast pumps and necessary replacement supplies.

Medical-Necessity & Preventive Criteria

General Preventive Coverage Conditions

Covered when ALL of the following are met:

ALL of the following

Service is an evidence-based item or service recommended with 'A' or 'B' rating by the US Preventive Services Task Force (USPSTF).
Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) for routine use are covered.
For infants, children and adolescents, services in HRSA/AAP Bright Futures comprehensive guidelines are covered.
Additional preventive care and screenings as provided in comprehensive HRSA guidelines are covered.
Service is provided by a Network provider for non-grandfathered plans to be covered without member cost sharing.

Preventive vs Diagnostic Determination

A service is considered preventive when ANY of the following apply:

ANY of the following

Person has not had the preventive screening before and has no symptoms or abnormal studies suggesting abnormalities.
Person had screening within recommended interval with normal findings.
Person had diagnostic services that were normal and future care is recommended on preventive screening intervals.

Diagnostic services are when ANY of the following are true

Abnormalities were found on previous preventive or diagnostic studies that require further diagnostic studies.

Breastfeeding Equipment Benefit

Covered when ALL of the following are met:

ALL of the following

Personal-use electric breast pump is limited to one pump per birth (even with multiple infants only one pump is covered).
Purchase of a personal-use electric breast pump is covered (HCPCS code E0603).
A breast pump purchase includes necessary supplies for the pump to operate (listed supply items).
Replacement breast pump supplies necessary for operation are covered (standard power adaptor; tubing adaptors, tubing, locking rings, pump-specific bottles and caps, valves, filters, breast shield and/or splash protector).

General Preventive Benefit Instructions

Covered when the following program-level conditions are met:

ALL of the following

Provider must adhere to FDA and CDC age/frequency guidelines for immunizations and vaccines.
Age-specific preventive benefit instructions apply per listed procedure code (e.g., Pediatric: birth to 21 years ends on 21st birthday; Adult: 21 years+).
Certain items have specified frequency (e.g., venipuncture 1x/year; vision screening 1x/year).
EmblemHealth Medicaid plans only reimburse codes if they are found on the Medicaid fee schedules (clarification in Coverage Limitations and Exclusions).

Vision Screening in Children

Covered when ALL of the following are met:

ALL of the following

Visual acuity screening (CPT 99173): Frequency: 1x/year; Ages: 0-21 years; ICD-10: Z00.121, Z00.129
Instrument-based screening (CPT 99174, 99177): Frequency: 1x/year; Ages: 1-4 years; ICD-10: Z00.129

Venipuncture & Capillary Blood Specimen

Covered when ALL of the following are met:

ALL of the following

Procedure CPT 36415 / 36416 - Frequency: 1x/year; ICD-10 Diagnosis for 36416: Z01.419

Immunizations (general)

Covered when ALL of the following are met:

ALL of the following

Administration codes as listed must be used (adult and pediatric administration CPT codes listed below).
Specific vaccine codes are covered when provided according to FDA/CDC age and frequency guidance and the age ranges specified per code in this policy.
COVID-19 vaccines: provider must adhere to FDA/CDC age/frequency guideline; ICD-10 Z23 applies for administration.

Provider Actions & Billing Guidance

Documentation Required

Report preventive vs diagnostic intent appropriately

Providers must report whether a service is preventive or diagnostic. Preventive services that meet the policy criteria and are reported appropriately will be considered under the preventive care services benefit; diagnostic services billed as non-preventive will be adjudicated under the applicable medical benefit. Use the policy criteria to determine preventive vs diagnostic intent (e.g., asymptomatic screening vs prior abnormal findings or symptoms).

Prior Authorization

Prior authorization may apply for BRCA genetic testing

Breast cancer (BRCA) genetic testing codes are listed in the policy; prior authorization requirements may apply. Obtain prior authorization when required by the member's plan.

81162
81163
81164
81165

Coding — Procedure & Vaccine Codes

Preventive Screening/Well Visit CPT (General)CPTCovered

99383	Preventive screening examination
99384	Preventive screening examination
99385	Preventive screening examination
99386	Preventive screening examination
99387	Preventive screening examination
99393	Preventive screening examination
99394	Preventive screening examination
99395	Preventive screening examination
99396	Preventive screening examination
99397	Preventive screening examination

Well Child VisitsCPTCovered

99381	New patient preventive visit (infant)
99382	New patient preventive visit (child)
99391	Established patient preventive visit (infant)
99392	Established patient preventive visit (child)

Immunization AdministrationCPTCovered

90460	Immunization administration (pediatric)
90461	Immunization administration (pediatric)
90471	Immunization administration (single adult/pediatric)
90472	Immunization administration (each additional)
90473	Immunization administration
90474	Immunization administration
90480	COVID-19 vaccine administration code (admin code)

Breast Pumps and Supplies (HCPCS)HCPCSCovered

E0602	Breast pump, rental
E0603	Personal-use electric breast pump (purchase)
A4281	Breast pump supply - tubing
A4282	Breast pump supply
A4283	Breast pump supply
A4284	Breast pump supply
A4285	Breast pump supply
A4286	Breast pump supply
A4287	Breast pump supply (new code effective 1/1/2024; frequency 200 units per 30 days)
A4288	Breast pump supply (new code effective 10/1/2025)

Preventive Counseling / Behavioral InterventionsCPTCovered

99401	Preventive medicine counseling, individual
99402	Preventive medicine counseling, individual
99403	Preventive medicine counseling, individual
99404	Preventive medicine counseling, individual
97802	Medical nutrition therapy
97803	Medical nutrition therapy
97804	Medical nutrition therapy
S9470	Dietary counseling code

Chlamydia / Gonorrhea / STI TestingCPT/HCPCSCovered

86631	Chlamydia test
86632	Chlamydia test
87110	Culture
87270	Microbial testing
87320	Chlamydia NAAT
87490	Chlamydia NAAT
87810	Chlamydia test
0455U	Chlamydia and Gonorrhea combined testing (effective 1/1/2026)
87590	Gonorrhea test
87591	Gonorrhea test

1–10 of 13

1/2

Colorectal / Colon Cancer ScreeningmixedCovered

00811	Anesthesia for colonoscopy
00812	Anesthesia for colonoscopy
88305	Pathology
44388	Screening colonoscopy
44389	Screening colonoscopy
44391	Colonoscopy
45300	Colonoscopy, diagnostic
45303	Colonoscopy with biopsy
45305	Colonoscopy with polypectomy
45308	Colonoscopy with removal

1–10 of 25

1/3

Cancer Screening - Breast / Mammography / TomosynthesisCPTCovered

76641	Breast ultrasound
76642	Breast ultrasound
77046	Diagnostic mammography
77047	Diagnostic mammography
77048	Screening mammography
77049	Screening mammography
77061	Breast tomosynthesis
77062	Breast tomosynthesis
77063	Breast tomosynthesis or mammography (used in addition to mammography codes)
77065	Diagnostic mammography

1–10 of 12

1/2

Pap Smear / Cervical CytologyCPTCovered

88141	Cytopathology
88142	Cytopathology
88143	Cytopathology
88147	Cytopathology
88148	Cytopathology
88150	Cytopathology
88152	Cytopathology
88153	Cytopathology
88155	Cytopathology
88164	Cytopathology

1–10 of 15

1/2

Sexual Health / HIV / Hepatitis / STIsmixedCovered

86689	HIV antibody test
86701	HIV test
86702	HIV test
86703	HIV test
87389	HIV test
87390	HIV test
87391	HIV test
87806	HIV test
86803	Hepatitis C test
86804	Hepatitis C test

1–10 of 12

1/2

Lung Cancer ScreeningCPTCovered

71271

Low dose CT chest (LDCT) for lung cancer screening

Diabetes / Lipid / Laboratory ScreeningCPTCovered

82947	Glucose; blood, quantitative
82948	Glucose; blood, other
82950	Glucose tolerance test
82951	Glucose tolerance test
82952	Glucose tolerance test
83036	Hemoglobin A1c
80061	Lipid panel
82465	Cholesterol
83718	Lipoprotein
83719	Lipoprotein

1–10 of 13

1/2

PrEP Counseling/Administration and MonitoringCPT/HCPCSCovered

G0013	Counseling for PrEP to prevent HIV (GO011/G0013 referenced)
G0011	Placeholder referenced (GO011 in text)
J0739	Injection cabotegravir (administration J-code referenced)
82565	Creatinine test (PrEP monitoring 3x per year)
82575	Creatinine test (PrEP monitoring 3x per year)
81025	Pregnancy screening (urine)
84702	Pregnancy test
84703	Pregnancy test
81002	Urinalysis
81003	Urinalysis

1–10 of 11

1/2

Venipuncture / Specimen CollectionCPTCovered

36415	Venipuncture
36416	Capillary blood specimen collection

Hearing and Vision Screening (Children)CPTCovered

99173	Visual acuity screening
99174	Instrument-based vision screening
99177	Instrument-based vision screening
92551	Screening test, pure tone
92552	Pure tone audiometry
92553	Speech audiometry
92558	Screening of hearing
92587	Evoked otoacoustic emissions test
92588	Evoked otoacoustic emissions test
92650	Hearing screening

1–10 of 11

1/2

Maternity / Prenatal PanelsmixedCovered

59425	Maternity antepartum care
59426	Maternity antepartum care
59400	Global maternity care
59510	Global maternity care
59610	Global maternity care
59618	Global maternity care
80081	Obstetric panel (includes HIV testing)
80055	Pregnancy screening panel
86901	Rh (D) typing

Osteoporosis Screening (DXA / Ultrasound codes)CPTCovered

76977	Ultrasound bone density
77080	Bone density study, single or dual energy X-ray absorptiometry (DXA)
77081	Bone density study, whole body

Autism Developmental ScreeningCPTCovered

96110

Developmental screening

Anemia Screening in Children (CBC codes)CPTCovered

85014	CBC automated
85018	Hemoglobin

Pap / HPV DNA TestingCPTCovered

87624	HPV testing
87625	HPV testing
87626	HPV testing (new code effective 1/01/2025)

Dental Fluoride Varnish (Pediatric)CPTCovered

99188

Oral fluoride varnish by pediatrician/PCP

Smoking Cessation CounselingCPTCovered

99406	Smoking cessation counseling
99407	Smoking cessation counseling
99401	Preventive counseling (also used for smoking cessation)
99402	Preventive counseling
99403	Preventive counseling

Contraception / SterilizationmixedCovered

99401	Contraceptive counseling (included in wellness visit)
99402	Contraceptive counseling
99403	Contraceptive counseling
99404	Contraceptive counseling
99202	Contraceptive management visit (example CPT list)
99203	Contraceptive management visit
99204	Contraceptive management visit
99213	Contraceptive management
11976	Implantable device (capsule removal)
11981	Implant insertion

1–10 of 31

1/4

Miscellaneous (Screenings / Tests)mixedCovered

96160	Health risk assessment, brief
96161	Health risk assessment, extended
99501	Breastfeeding counseling
99502	Breastfeeding counseling
S9443	Breastfeeding support services

Venipuncture & Capillary Blood SpecimenCPTCovered

36415	Venipuncture
36416	Capillary blood specimen; ICD-10 Diagnosis = Z01.419

Vision ScreeningCPTCovered

99173	Visual acuity screening
99174	Instrument-based vision screening
99177	Instrument-based vision screening

Immunization administration (Adult & Pediatric)CPTCovered

90460	Immunization administration (pediatric)
90461	Immunization administration (pediatric)
90471	Immunization administration (both adult and pediatric)
90472	Immunization administration
90473	Immunization administration
90474	Immunization administration
90480	Immunization administration (COVID-19 admin listed)

COVID-19 vaccine product codesCPT/HCPCSCovered

91304	COVID-19 vaccine - Novavax
91318	COVID-19 vaccine - Pfizer-BioNTech
91319	COVID-19 vaccine - Pfizer-BioNTech
91320	COVID-19 vaccine - Pfizer-BioNTech
91321	COVID-19 vaccine - Moderna
91322	COVID-19 vaccine - Moderna
91323	COVID-19 vaccine - Moderna (added per revision)
91304-91323	COVID-19 vaccine product codes listed in policy

Selected vaccine product and administration codes (representative, not exhaustive)CPTCovered

90587	Dengue vaccine (Dengvaxia) - provider must adhere to FDA/CDC age/frequency guidelines
90702	DT (Diphtheria, tetanus)
90700	DTaP
90723	DtaP-HepB-IPV (Pediatrix)
90696	DTaP-IPV (Kinrix, Quadracel)
90697	DTaP-IPV-Hib-HepB (Vaxelis)
90698	DTaP-Hib-IPV
90714	Td (tetanus and diphtheria)
90715	Tdap (Adacel, Boostrix)
90632	Hepatitis A

1–10 of 58

1/6

Background

The purpose of this policy is to implement PPACA-required coverage of USPSTF A/B recommendations, routine ACIP immunization recommendations, and HRSA/AAP Bright Futures pediatric preventive guidelines so that eligible preventive services are provided consistent with federal guidance. It clarifies how services are classified as preventive (eligible when performed for routine screening in asymptomatic individuals or per recommended intervals) versus diagnostic (when performed for symptoms, abnormal prior findings, or outside guideline populations), and directs providers to report the appropriate preventive versus diagnostic intent. The policy also notes that state mandates may affect required coverage and that grandfathered plans are not legally required to provide these preventive services without member cost sharing, though they may choose to do so; non-grandfathered plans must provide in-network preventive coverage without member cost sharing.

Revision History

10/14/2025material_addedLatest

Added HCPCS code A4288 to Breast Pump Supplies effective 10/1/2025.

9/18/2025material_added

Included COVID-19 vaccine product code 91323 (Moderna) effective 8/27/2025.

9/4/2025material_added