CurrentFlorida BluePolicy N/A

Preventive Services and Screening Coverage Guidance

Summarizes USPSTF recommendations and Florida Blue coverage stance for preventive screening, counseling, preventive medications, and immunizations for members; affects in-network providers delivering preventive services and prenatal/wellness care.

Policy Summary

PayerFlorida Blue

PolicyPreventive Services and Screening Coverage Guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill recommended preventive services with routine/preventive diagnosis codes or as part of annual wellness or prenatal visits to obtain $0 cost-sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$0Coverage cost-sharing stance for many services

multipleUSPSTF recommendations summarized

severalAge-based criteria present

2 groupsImmunization groups listed

Covered Preventive Services and Screening

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U.S. Department of Health & Human Services (HHS) — Screening for sexually transmitted infections (STIs) and HIV: Counseling for STIs and screening tests for chlamydia, gonorrhea, hepatitis B, and syphilis are covered at $0 when billed with a routine preventive diagnosis (e.g., as part of a well woman exam). HIV screening is covered at $0 when billed as preventive; initial screening is recommended for all adolescent and adult women (≥15 years) with additional/annual screening based on risk and for pregnant women at initiation of prenatal care (rescreening during pregnancy as indicated). Rapid HIV testing for women presenting in active labor without documented HIV status is also included.

HHS — Contraceptive services and counseling: Education and counseling related to contraceptives and sterilization are covered at $0. Covered contraceptive methods include, but are not limited to, surgical sterilization, contraceptive implants, copper and progestin intrauterine devices (all durations), injectable contraceptives, combined and progestin-only oral contraceptives (including extended/continuous use formulations), transdermal patch, vaginal ring, diaphragms, sponges, cervical caps, condoms, spermicides, emergency contraception (levonorgestrel and ulipristal acetate), and any additional FDA-approved contraceptives. Contraceptive care also includes screening, provision, and follow-up (management, evaluation, removal, continuation, discontinuation). Note: Certain employer-sponsored plans with religious exemptions may have different coverage.

HHS — Lactation services and equipment: Comprehensive lactation support and counseling (prenatal, perinatal, and postpartum), including consultation and peer support services, are covered at $0 (prenatal lactation counseling covered as part of OB/GYN counseling; postpartum support provided as needed in hospital or OB/GYN office). Breastfeeding equipment (e.g., manual or electric breast pumps and breast milk storage supplies) are covered when obtained through the plan's preferred durable medical equipment (DME) provider. Coverage is limited to one manual or electric pump per pregnancy and is subject to the plan's DME coverage rules. Prior coverage authorization from the plan is required for breast pump coverage; without prior authorization the pump may not be covered.

HHS — Screening and counseling for interpersonal and domestic violence: Annual screening for interpersonal and domestic violence (including physical, sexual, stalking, psychological aggression/coercion, reproductive coercion, neglect, and threats) for adolescents and women is recommended and covered at $0 when billed with a routine preventive diagnosis (e.g., as part of a well woman exam). When screening is positive, provision or referral for initial intervention services is covered.

Covered Preventive Services — Examples

Examples of covered preventive services — these are covered when billed appropriately (routine preventive/wellness diagnosis codes or as otherwise specified).

Sexually transmitted infection (STI) screening (examples): Chlamydia screening, Gonorrhea screening, Hepatitis B screening, Syphilis screening — covered at $0 when billed with a routine preventive diagnosis (e.g., as part of a well woman exam) per WPSI/HHS guidance.

HIV screening: One-time screening for adolescents and adults starting at age 15, with earlier/additional screening based on risk; pregnant women screened at initiation of prenatal care and rescreened during pregnancy as indicated — covered at $0 when billed as preventive. Rapid HIV testing for women in active labor without documented status is included.

Contraceptive services (examples): Counseling and education; provision and follow-up for contraceptives including implants, IUDs (copper and progestin), injectables, oral contraceptives (combined and progestin-only, including extended/continuous), patch, vaginal ring, diaphragms, sponges, cervical caps, condoms, spermicides, emergency contraception (levonorgestrel, ulipristal), surgical sterilization — covered at $0 when billed per WPSI/HHS. See plan formulary/list for specific covered products and any dispensing rules.

Lactation support and equipment (examples): Prenatal and postpartum lactation counseling and support services covered at $0 when billed as prenatal/OB or preventive services; one manual or electric breast pump per pregnancy covered when obtained through the plan's preferred DME vendor and after prior coverage authorization. Breast milk storage supplies and counseling included as specified by WPSI/HHS and plan DME policy.

Domestic/interpersonal violence screening and counseling: Annual screening and initial intervention or referral services are covered at $0 when billed as part of a routine preventive or well woman visit.

Coverage Notes — Preventive Billing Guidance

Cervical cancer screening, STI/HIV testing, contraceptive care, lactation support, and domestic violence screening are preventive when billed with routine preventive diagnosis codes as described below.

Cervical cancer screening: Pap testing and HPV screening per USPSTF/WPSI recommendations are covered at $0 when billed as part of a preventive/well woman exam.

STI counseling and screening: Behavioral counseling for STI prevention and the associated screening tests listed above are covered at $0 when billed with a routine preventive diagnosis code.

Contraceptive counseling and provision: Counseling, method provision, and related follow-up care (including device insertion/removal and surgical sterilization) are covered at $0 when billed as preventive/well woman services; coverage details and product lists are available on the plan’s preventive medications and DME pages.

Lactation services and equipment: Clinical lactation support/counseling covered at $0; breast pumps and supplies covered via preferred DME vendor with limitation of one pump per pregnancy and prior coverage authorization requirement.

Domestic violence screening: Annual screening and referral/intervention services covered at $0 when billed as part of routine preventive care.

Codes, Age Groups, and Eligibility Criteria

No codes in excerptmixed

No codes listed

Durable Medical Equipment (breastfeeding equipment)mixed

breast pump (durable medical equipment) - prior authorization required if not obtained through preferred DME provider; limited to one manual or electric pump per pregnancy

No explicit CPT/HCPCS/ICD codes in these preventive service chunksmixed

No codes listed

Covered preventive services when billed with routine diagnosisneutralCovered

No codes listed

inv-30: Lung cancer screening age and risk — Adults 50-80 years with 20 pack-year history and smoking status criteria

Age rangeAdults 50–80 years

Smoking history≥20 pack-year history

Current/former smoker ruleCurrently smoke or quit within the past 15 years

Discontinuation criteriaStop screening if person has not smoked for 15 years or has health problems limiting life expectancy or ability/willingness to have curative lung surgery

inv-31: Breast cancer screening frequency and ages (Florida Blue) — baseline and mammogram frequency notes

USPSTF frequencyBiennial (every 2 years) mammography for women aged 40–74 (USPSTF)

Florida Blue baselineBaseline mammogram for women between ages 35 and 40 (Florida Blue)

Florida Blue frequency 40–50Mammogram every 2 years for women between ages 40 and 50 (Florida Blue) — screenings covered at $0 as part of annual wellness exam

Screening continuationScreening should continue through at least age 74; annual screening acceptable

inv-32: Obesity screening BMI threshold — adults BMI >= 30

BMI thresholdAdults with body mass index (BMI) ≥30 kg/m²

InterventionOffer or refer to intensive, multicomponent behavioral interventions

CoverageThese services are covered at $0 as part of annual wellness exam

inv-33: Lung cancer screening eligibility — reiteration of age and smoking history criteria

Age rangeAdults 50–80 years

Smoking history20 pack-year smoking history

Smoking statusCurrently smoke or quit within past 15 years

DiscontinuationDiscontinue if not smoked for 15 years or if major health problems limit life expectancy or curative surgery

inv-34: Statin primary prevention eligibility — adults 40-75 with ≥1 CVD risk factor and 10-year risk ≥10%

Age rangeAdults 40–75 years

Risk factors requiredAt least 1 cardiovascular disease (CVD) risk factor (e.g., dyslipidemia, diabetes, hypertension, or smoking)

Calculated 10-year risk10-year CVD event risk ≥10%

Recommended therapyLow- to moderate-dose statin for primary prevention when criteria met

inv-35: Depression and obesity screening thresholds — adolescents 12-18 for depression; adults BMI >=30

Adolescent depression screeningScreen adolescents ages 12–18 for major depressive disorder; ensure systems for accurate diagnosis, treatment, and follow-up

Adult depression screeningScreen adults (including pregnant and postpartum) when systems ensure diagnosis and follow-up

Obesity thresholdAdults with BMI ≥30 should be offered intensive, multicomponent behavioral interventions

inv-36: Cervical cancer screening intervals — Pap every 3 years 21-29; cytology+HPV or cytology alone intervals for 30-65

Women 21–29Cervical cytology (Pap) every 3 years

Women 30–65Either cytology alone every 3 years, high-risk HPV (hrHPV) testing alone every 5 years, or hrHPV plus cytology co-testing every 5 years

Coverage noteScreening covered at $0 as part of annual wellness exam when billed with routine diagnosis codes

inv-37: Breast cancer screening — begin between 40-50; screening at least every 2 years (annual acceptable); continue through at least specified age

Initiation ageBegin screening not before age 40 and not after 50 (WPSI guidance for average-risk women)

Frequency minimumPerform screening at least every 2 years (annual frequency acceptable)

Continuation ageContinue screening through at least age 74; do not discontinue based on age alone

inv-38: Postpartum diabetes screening interval — initial within first year postpartum (can be 4-6 weeks); repeat schedule if negative

Initial postpartum timingInitial screening within the first year postpartum; may be done as early as 4–6 weeks postpartum

Repeat schedule if negativeIf initial test is negative, repeat at least every 3 years for a minimum of 10 years after the pregnancy

Confirmatory testingFor positive postpartum diagnostic test, confirm diagnosis with appropriate confirmatory testing (e.g., oral glucose tolerance test, fasting plasma glucose, or hemoglobin A1c)

Billing, Authorization, and Documentation Requirements

Billing Rule

Check formulary/participating pharmacy for preventive medications

Check the drug formulary and confirm the member’s participating pharmacy before prescribing or dispensing preventive medications. Some preventive pharmacotherapies (e.g., aspirin for preeclampsia prevention, statins for primary prevention, raloxifene/tamoxifen/anastrazole for breast cancer risk reduction, PrEP agents) require a prescription and must be obtained through a participating pharmacy to be covered at $0. Click the payer’s preventive medications list or formulary to verify coverage and any pharmacy or prior authorization requirements.

Confirm medication is on the preventive medications list (see payer link).
Verify participating pharmacy network for $0 coverage.
Obtain and document prescription when required.

Billing Rule

Coverage tied to preventive visit billing

Many women's preventive services and screenings are covered at $0 when billed as part of a preventive visit. To ensure $0 cost-sharing, bill these services with a routine/wellness diagnosis code or as part of an annual wellness, well-woman, prenatal, or child well visit as appropriate.

Bill breast, cervical, colorectal, and other USPSTF-recommended screenings as part of the annual wellness or well-woman exam to obtain $0 cost-sharing.
Bill breastfeeding interventions and lactation counseling as part of prenatal/postpartum care for $0 coverage.
Bill gestational diabetes screening, HIV screening in pregnancy, and prenatal preventive services with routine prenatal/well-woman diagnosis codes.

Billing Rule

Billing as preventive

Services must be billed as preventive (routine/well visit) to be eligible for $0 cost-sharing. If billed with a non-routine diagnostic code or outside of the preventive visit context, standard benefit cost-sharing may apply.

Use appropriate routine/wellness diagnosis codes for well woman visits, annual wellness exams, prenatal well visits, and child well visits.
Breastfeeding equipment (breast pump) and lactation supplies require prior coverage authorization and must be obtained through the preferred DME vendor; billing as preventive does not replace prior authorization requirements.

Billing Rule

Billing with routine diagnosis code to obtain $0 cost-sharing

To obtain $0 cost-sharing for eligible preventive services, bill screenings and counseling with a routine diagnosis code (for example: well-woman exam, annual wellness visit, prenatal visit). This applies to many USPSTF and HHS/WPSI recommended services, including cancer screenings, contraceptive services, STIs/HIV screening, tobacco cessation counseling in pregnancy, and postpartum diabetes screening after gestational diabetes.

Examples of services commonly requiring routine diagnosis coding for $0 coverage: mammography, cervical cancer screening (Pap/HPV), chlamydia/gonorrhea/HBV/syphilis/HIV screenings, gestational diabetes screening, tobacco cessation counseling for pregnant women.
When submitting claims, include the preventive visit diagnosis code on the same claim line or as part of a bundled preventive visit claim to ensure $0 cost-sharing is applied.

Key Definitions and USPSTF Grade Meaning

inv-56: USPSTF Grade definitions — Grade A/B definitions summary

Grade A definitionUSPSTF recommends the service; there is a high certainty that the net benefit is substantial

Grade B definitionUSPSTF recommends the service; there is high certainty that the net benefit is moderate or moderate certainty that net benefit is moderate to substantial

UsageGrade A and B recommendations are used in this policy as the basis for coverage of preventive services at $0 when billed appropriately

inv-57: USPSTF Grade definitions — alternative definition grouping for Grade A/B

Grade A (alternate wording)The USPSTF recommends the service; there is high certainty the net benefit is substantial

Grade B (alternate wording)The USPSTF recommends the service; there is high certainty that the net benefit is moderate or moderate certainty that net benefit is moderate to substantial

Language noteDefinitions are presented here in alternate (Spanish) phrasing consistent with USPSTF definitions used in the policy

inv-58: USPSTF recommendation grade — repeated citation of Grade A/B as basis for coverage

Policy basisThe document repeatedly cites USPSTF Grade A and B recommendations as the basis for coverage decisions

Coverage implicationServices recommended as Grade A or B are described as covered at $0 when billed as preventive or with routine diagnosis codes

ScopeThis underpinning applies across multiple preventive services summarized in the policy (screening, counseling, preventive medications)

inv-59: Well-woman visit — definition of annual preventive visit for women

DefinitionAnnual preventive visit for women beginning in adolescence and continuing through life to ensure receipt of recommended preventive services (including preconception and prenatal/interpregnancy care)

Coverage noteAll routine women's preventive services are available at $0 when billed with a routine diagnosis code (e.g., as part of a woman's routine well visit)

FrequencyAt least one preventive care visit annually

inv-60: Postpartum diabetes screening definition — timing for initial postpartum screening

Initial timingInitial postpartum diabetes screening should occur within the first year postpartum and can be performed as early as 4–6 weeks after delivery

Repeat interval if negativeRepeat testing at least every 3 years for a minimum of 10 years if the initial postpartum test is negative

Target populationWomen with a history of gestational diabetes who are not currently pregnant and without prior type 2 diabetes

Policy Summary

PayerFlorida Blue

PolicyPreventive Services and Screening Coverage Guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill recommended preventive services with routine/preventive diagnosis codes or as part of annual wellness or prenatal visits to obtain $0 cost-sharing.

SourceLink

On This Page

OpenPayer

Preventive Services and Screening Coverage Guidance

Covered Preventive Services and Screening

Codes, Age Groups, and Eligibility Criteria

Billing, Authorization, and Documentation Requirements

Policy Background and Scope

Key Definitions and USPSTF Grade Meaning