CurrentFlorida BluePolicy N/A

USPSTF Grade A & B Preventive Services Coverage (In-Network)

Defines USPSTF Grade A and B recommended preventive services and describes Florida Blue coverage stance (cost-sharing and settings) for those services when delivered in-network.

Policy Summary

PayerFlorida Blue

PolicyUSPSTF Grade A & B Preventive Services Coverage (In-Network)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill preventive services with a routine/well‑woman or preventive diagnosis code and obtain prior authorization for breast pumps through the preferred DME vendor to secure coverage at $0.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleUSPSTF topics summarized

$0Many screenings covered with no cost sharing

50-80Lung LDCT age range

1/pregnancyBreast pump limit

21-65Cervical screening ages

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Coverage Criteria for USPSTF Grade A & B Preventive Services

Selected Covered Preventive Services with Criteria

Coverage summaries for selected USPSTF Grade A/B recommendations (document lists many topics; examples below reflect text in this excerpt):

Abdominal aortic aneurysm (AAA) screening: USPSTF recommends one-time AAA screening by ultrasonography in men ages 65-75 who have ever smoked; Florida Blue covers one-time screening for men 65-75 with a history of smoking at $0 in-network.men ages 65-75 with history of smoking

chunk 2

Breast cancer screening: USPSTF recommends biennial screening mammography for women aged 50-74; Florida Blue also covers a baseline mammogram for women 35-40 and a mammogram every two years for women 40-50, covered at $0 as part of an annual wellness exam.women aged 50-74 (USPSTF); payer additions ages 35-50

chunk 5

Cervical cancer screening: USPSTF: women 21-29 cytology every 3 years; women 30-65 cytology every 3 years or hrHPV alone every 5 years or cotesting every 5 years. Florida Blue covers these screenings at $0 as part of annual wellness exam.age 21-65

chunk 7

Lung cancer screening: USPSTF: annual low-dose CT for adults 50-80 with a 20 pack-year smoking history who currently smoke or quit within past 15 years; discontinue after 15 years since quitting or if life expectancy precludes curative surgery. Florida Blue covers annual screening for qualifying members.ages 50-80; 20 pack-year; quit <15 years

chunks 13,42

Depression screening: USPSTF recommends screening adolescents (12-18) and adults (including pregnant/postpartum) when systems exist for diagnosis and follow-up; Florida Blue covers these screenings at $0 as preventive visits.adolescents 12-18; adults including pregnant/postpartum

chunks 7,9,38

Diabetes screening: USPSTF recommends screening adults 35-70 with overweight or obesity for prediabetes and diabetes; Florida Blue covers screening at $0 as part of annual wellness exam.age 35-70 with overweight/obesity

chunk 9

Prenatal screenings and interventions: Multiple USPSTF-recommended prenatal screenings/interventions (bacteriuria, hepatitis B, gestational diabetes, Rh testing, preeclampsia screening) are covered at $0 as part of prenatal care; low-dose aspirin for preeclampsia prevention and certain preventive medications are covered at $0 with prescription at participating pharmacies.gestation-specific timing per recommendation

chunks 2,10,16,17

STI screening and counseling: USPSTF recommends screening/counseling for chlamydia, gonorrhea, syphilis, HIV and counseling for sexually active adolescents/adults at increased risk; Florida Blue covers these services at $0 as part of annual wellness or prenatal care where specified.age and risk-based; see individual recommendations

chunks 7,11,13,19

Preventive medications: USPSTF recommends certain medications (e.g., aspirin for preeclampsia prevention, statins for primary prevention in select adults, BRCA-related preventive meds) and Florida Blue lists coverage at $0 for specified medications with prescription and refers to a complete preventive medicines list.age and risk criteria per USPSTF

chunks 5,16,18,50

Behavioral counseling (diet, activity, tobacco, skin cancer, IPV): USPSTF recommends counseling for multiple preventive topics (healthy diet/physical activity for CVD risk, tobacco cessation, skin cancer prevention for ages 6 months–24 years, IPV screening for reproductive-age women); Florida Blue covers these counseling services at $0 when billed as part of annual wellness exam or preventive visit.age and risk-based per topic

chunks 2,11,18,44

Statin use for primary prevention (USPSTF)

Covered when ALL of the following are met

Statin primary prevention criteria: Adults aged 40-75 years; one or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking); calculated 10-year CVD event risk ≥ 10%10-year risk >= 10%

chunks 18,50

Universal lipids screening supporting statin decisions

Covered when ALL of the following are met

Lipid screening for risk calculation: Universal lipids screening in adults aged 40-75 years to identify dyslipidemia and calculate 10-year cardiovascular risk to inform statin decisions.age 40-75

chunks 19,50

Syphilis and HIV screening

Covered when applicable

Syphilis screening (nonpregnant): Screen nonpregnant adolescents and adults who are at increased risk for syphilis; covered at $0 as part of annual wellness exam.nonpregnant = increased risk

chunk 19

Syphilis screening (pregnancy): Screen all pregnant women early in pregnancy for syphilis; covered at $0 as part of prenatal care.pregnancy = all

chunks 19,13

HIV screening: Screen adolescents and adults (USPSTF: ages 15-65 and others at increased risk); all pregnant persons should be screened including at initiation of prenatal care; covered at $0 as part of annual wellness exam or prenatal care.at least once age >=15; repeat per risk; pregnant = at initiation

Cervical and breast cancer screening (WPSI & USPSTF)

Covered when billed with routine diagnosis code

Cervical cancer screening: Women 21-29: cervical cytology every 3 years. Women 30-65: cervical cytology every 3 years OR hrHPV testing alone every 5 years OR hrHPV plus cytology (co-testing) every 5 years. Covered at $0 when billed with a routine/well-woman diagnosis code (as part of a well-woman exam).age 21-65

chunks 7,22,55

Breast cancer screening (USPSTF and WPSI/Florida Blue additions): USPSTF: biennial mammography for women 50-74. WPSI/Florida Blue: baseline mammogram for women 35-40 and mammography every two years for women 40-50. These screenings are covered at $0 when billed with a routine/well-woman diagnosis code.age ranges vary by guideline

chunks 5,56,62

Other USPSTF-covered screenings

Covered when applicable and billed as preventive

BRCA risk assessment and genetic counseling/testing: Evaluate women with personal or family history of breast/ovarian/peritoneal cancer or ancestry associated with BRCA1/2 using a brief familial risk assessment tool; positive results should lead to genetic counseling and testing if indicated. Covered at $0 as part of annual wellness exam.history suggestive of hereditary risk

chunk 5

Colorectal cancer screening: Screen adults beginning at age 45 through 75; covered at $0 as part of annual wellness exam when provided as preventive service.age 45-75

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Dental caries prevention (children): Apply fluoride varnish to primary teeth starting at tooth eruption and prescribe oral fluoride supplements from 6 months where water fluoride is low; covered as part of well-child visit.

Contraceptive methods and counseling (WPSI)

Covered when billed with routine diagnosis code

Contraceptive care and counseling: Access to the full range of contraceptives including education, counseling, provision, follow-up and sterilization; includes listed devices and FDA-approved methods. Covered at $0 when billed with a routine/well-woman diagnosis code (employer religious exemptions may apply).N/A

chunks 24,58

Breastfeeding support and interventions

Covered when applicable

Lactation support services: Comprehensive lactation support including consultation, counseling, education and peer support during antenatal, perinatal, and postpartum periods; covered at $0 as part of prenatal care or OB/GYN counseling.N/A

chunk 25

Breastfeeding equipment (breast pumps): Breastfeeding equipment must be obtained through the preferred DME provider, limited to one manual or electric pump per pregnancy; prior coverage authorization is required and equipment is subject to DME coverage guidelines; failure to obtain prior authorization will result in noncoverage.one pump per pregnancy

chunks 25,59

Cervical cancer screening

Covered preventive services when provided to indicated populations and billed as preventive or as part of prenatal/wellness visits

Cervical cancer screening (ages 21-65): For women 21-29: cervical cytology alone every 3 years. For women 30-65: cervical cytology alone every 3 years OR hrHPV testing alone every 5 years OR hrHPV plus cytology (co-testing) every 5 years. Covered at $0 as part of annual wellness or well-woman visit when billed with routine diagnosis.age 21-65

chunks 7,55

STI screening

Covered STI screening for indicated populations

Chlamydia screening (women): Test sexually active women <25 years and older women at increased risk; includes pregnant women. Covered at $0 as part of annual wellness or prenatal care when billed as preventive.age <25 or increased risk

chunk 7

Gonorrhea screening (women): Test sexually active women <25 years and older women at increased risk; includes pregnant women. Covered at $0 as part of annual wellness or prenatal care when billed as preventive.age <25 or increased risk

chunk 11

Syphilis and hepatitis screening: Screen persons at increased risk for syphilis; screen all pregnant women early in pregnancy for syphilis; screen pregnant women for hepatitis B at first prenatal visit; covered at $0 as part of annual wellness or prenatal care.

Depression screening

Depression screening for adolescents and adults

Adolescent depression screening: Screen adolescents aged 12-18 for major depressive disorder (MDD); covered at $0 as part of annual wellness exam.age 12-18

chunk 38

Adult depression screening: Screen adults including pregnant and postpartum women when systems ensure accurate diagnosis, effective treatment, and adequate follow-up; covered at $0 as part of annual wellness or well-woman visit.adults including pregnant/postpartum

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Diabetes screening

Diabetes and gestational diabetes screening

Type 2 diabetes/prediabetes screening (adults): Screen adults 35-70 years with overweight or obesity for prediabetes and diabetes; offer or refer to preventive interventions; covered at $0 as part of annual wellness exam.age 35-70 with overweight/obesity

chunk 9

Gestational diabetes screening: Screen asymptomatic pregnant women after 24 weeks' gestation (preferably between 24 and 28 weeks); covered at $0 as part of prenatal care.pregnancy >24 weeks; prefer 24-28 weeks

chunks 10,61

Postpartum diabetes screening after GDM: Women with prior gestational diabetes should have initial screening within the first year postpartum (can be 4-6 weeks); if negative, repeat at least every 3 years for 10 years; confirmatory testing required for positive results. Covered at $0 when billed with routine diagnosis.

Lung cancer screening

Annual low-dose CT for high-risk individuals

Lung cancer screening (LDCT): Annual low-dose CT for adults 50-80 years with a 20 pack-year smoking history who currently smoke or quit within past 15 years; discontinue screening if quit >15 years, limited life expectancy, or not a candidate for curative surgery. Covered annually for eligible members.age 50-80; 20 pack-year; current or quit ≤15 yrs

chunks 13,42

Immunizations

Recommended immunizations

Pediatric immunizations: Routine childhood vaccines from birth through 18 years including HepB, rotavirus, DTaP, Hib, pneumococcal conjugate, IPV, influenza, MMR, varicella, HepA, Tdap (≥7 yrs), HPV, meningococcal, meningococcal B, and PPSV as indicated; refer to CDC schedule.birth-18 yrs

chunk 52

Adult immunizations: Routine adult vaccines including influenza, Tdap/DT, MMR, varicella, recombinant zoster, HPV, pneumococcal (conjugate and polysaccharide), HepA, HepB, meningococcal A/C/W/Y and B, Hib as indicated; refer to CDC schedule.age >=19 yrs

chunk 53

Preventive medications and counseling

Medication and counseling preventive recommendations

Folic acid supplementation: Women planning pregnancy or capable of pregnancy should take 0.4–0.8 mg (400–800 µg) daily; folic acid tablets covered at $0 with prescription.women planning pregnancy

chunk 40

Low-dose aspirin for preeclampsia prevention: Use aspirin 81 mg/day after 12 weeks' gestation in women at high risk for preeclampsia; aspirin covered at $0 with prescription at participating pharmacies.pregnant women at high risk

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PrEP for HIV prevention: Offer pre-exposure prophylaxis with effective antiretroviral therapy to persons at high risk for HIV; refer to preventive medicines list for coverage details.high-risk individuals

Additional USPSTF screening & preventive services

Additional screening recommendations covered when indicated

Hepatitis B & C screening: Screen pregnant women for HBV at first prenatal visit; screen nonpregnant adolescents/adults at increased risk for HBV; screen all adults 18-79 for HCV. Covered at $0 as part of prenatal or annual wellness visits.as specified per USPSTF

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Intimate partner violence (IPV) screening: Screen women of reproductive age for IPV and provide or refer to ongoing support services; covered at $0 as part of annual wellness exam.women of reproductive age

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Latent TB screening: Screen adults at increased risk for latent tuberculosis infection; covered at $0 as part of annual wellness exam.increased risk populations

Covered preventive services (WPSI/HHS) — in-network coverage

Covered preventive services when billed as routine/well-woman care:

General rule

Cervical cancer screening: Women age 21-65: 21-29 cytology every 3 years; 30-65 co-testing HPV+cytology every 5 years or cytology every 3 years; do not screen more often than every 3 years for average-risk women. Covered at $0 when billed as routine/well-woman.ages 21-65
chunks 55-56
Gestational diabetes screening: Screen after 24 weeks gestation, preferably 24-28 weeks to prevent adverse birth outcomes; covered at $0 when billed with a routine diagnosis code.>24 weeks, prefer 24-28w
chunks 55,61
HIV screening (WPSI):

Screening for lung cancer with annual low-dose CT is covered for eligible members but screening should be discontinued once a person has not smoked for 15 years or if they develop a health problem that substantially limits life expectancy or the ability/willingness to have curative lung surgery. This aligns with the USPSTF criteria for adults ages 50–80 with a 20 pack-year history who currently smoke or quit within the past 15 years.

Breastfeeding equipment such as breast pumps must have prior coverage authorization to be covered. The policy states that a pump obtained without prior coverage authorization will not be covered under the policy.

This section does not list specific services as exclusions. No explicit excluded services are specified here; coverage guidance focuses on services that are covered when billed with the appropriate routine or well-woman diagnosis code.

Coverage for breast pumps requires obtaining prior coverage authorization and that the pump be obtained through the plan’s preferred durable medical equipment vendor. Equipment is limited to one manual or electric breast pump per pregnancy and is paid in accordance with DME coverage guidelines; failure to follow this process may result in noncoverage.

There are no explicit statements in this section labeling services as not medically necessary. The policy language provided describes covered preventive services and related coverage rules without forcefully designating any items here as not medically necessary.

Coding and Billing References

Immunizations (no specific CPT/HCPCS listed)mixed

No codes listed

Durable medical equipment (breast pumps) — coverage notes (no specific DME codes provided)mixedCovered

No codes listed

Preventive medications referenced (statins, tamoxifen, raloxifene, anastrozole) — prescription coverage at $0 when applicable (no CPT/NDC lists provided)NDC|mixedCovered

No codes listed

Billing guidance (no explicit codes provided)mixed

not listed

Document references billing with appropriate preventive/visit codes but does not list specific CPT/HCPCS/ICD-10 codes in this section.

Durable medical equipment / lactation supplies — billing (process applies; code-level billing neutral placeholder)mixed

not specified

Durable medical equipment process applies for breast pumps; prior authorization required; no specific HCPCS/DME codes listed.

Preventive service billing practice (guidance placeholder; no explicit code lists)mixed

not specified

Services must be billed with a routine/well-woman or preventive diagnosis to qualify for $0 cost-sharing; document does not list explicit CPT/HCPCS codes in these sections.

Contraceptive methods (covered) — code-group placeholder (no specific codes listed)mixedCovered

not specified

Wide range of contraceptive methods covered (sterilization, implants, IUDs, injectables, oral contraceptives, patch, ring, barrier methods, emergency contraception including levonorgestrel and ulipristal); no specific CPT/HCPCS codes provided in source.

Lung cancer screening eligibility — ages and smoking history summarized as key facts

Age range50–80 years

Smoking history≥20 pack-year history

Current/former smokerCurrent smoker or quit within past 15 years

Discontinuation ruleDiscontinue screening if quit >15 years or life expectancy/operative candidacy precludes curative surgery

Obesity screening BMI threshold

BMI threshold (adults)BMI ≥ 30 kg/m²

ActionOffer or refer to intensive, multicomponent behavioral interventions

Coverage contextCovered at $0 as part of annual wellness exam when billed as preventive

10-year CVD risk threshold

10-year CVD risk threshold>= 10%

Age range for considerationAdults aged 40–75 years

Additional criteriaOne or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and low- to moderate-dose statin recommended when criteria met

Lung cancer screening criteria

Age range50–80 years

Smoking exposure20 pack-year history

Tobacco statusCurrent smoker or quit within past 15 years

Discontinue criteriaStop screening if quit >15 years or if life expectancy/ability for curative surgery is limited

Obesity BMI threshold (adults)

BMI threshold (adults)BMI ≥ 30 kg/m²

Recommended interventionIntensive, multicomponent behavioral interventions

Coverage noteCovered at $0 as part of annual wellness exam when billed as preventive

Folic acid dose for pregnancy planning

Recommended dose0.4–0.8 mg (400–800 µg) daily

PopulationWomen planning pregnancy or capable of pregnancy

CoverageFolic acid tablets (400 mcg, 800 mcg) covered at $0 with prescription

Preeclampsia aspirin prophylaxis

Medication and doseLow-dose aspirin 81 mg/day

TimingStart after 12 weeks' gestation

PopulationWomen at high risk for preeclampsia

CoverageAspirin covered at $0 at participating pharmacies with prescription

Gestational diabetes screening window

Preferred screening windowPreferably between 24 and 28 weeks' gestation (after 24 weeks)

PopulationAsymptomatic pregnant women

CoverageCovered at $0 as part of prenatal care when billed appropriately

Cervical cancer screening ages

Age range21–65 years

Ages 21–29 intervalCervical cytology (Pap) every 3 years

Ages 30–65 intervalCytology every 3 years OR hrHPV alone every 5 years OR co-testing every 5 years

Billing noteCovered at $0 when billed with routine/well-woman diagnosis

Postpartum diabetes screening timing

Initial timingInitial screening within the first year postpartum (can be done at 4–6 weeks)

Follow-up interval if negativeRepeat at least every 3 years for 10 years after the pregnancy if initial postpartum test is negative

Confirmatory testingPositive postpartum diagnostic tests should be confirmed with standard diagnostic testing (e.g., OGTT, fasting plasma glucose, or HbA1c)

Provider Billing, Authorization, and Documentation Actions

Prior Authorization

Prior Authorization Required for Breast Pumps

Breast pumps (manual or electric) obtained through the plan’s preferred DME vendor require prior coverage authorization before delivery. If prior authorization is not obtained, the pump will not be covered under the policy.

Limited to one manual or electric breast pump per pregnancy.
No prescription required, but prior coverage authorization from the plan is mandatory.
Breastfeeding equipment must be obtained through the preferred durable medical equipment provider and is paid per the DME coverage guidelines.

Billing Rule

Billing Context for $0 Coverage

Coverage for many preventive and women’s services is $0 cost‑sharing when billed in the correct context. To receive $0 coverage, bill preventive services (including well woman services, gestational diabetes screening, and many USPSTF/HHS‑recommended services) with a routine/well‑woman or other appropriate preventive diagnosis code or as part of an annual wellness/prenatal visit.

Examples: annual wellness exam, well woman exam, or prenatal visit billing with a routine diagnosis code.
Many USPSTF Grade A/B services and WPSI‑recommended services are covered at $0 when billed in this manner.

Denial Risk

Denial Risk Summary

Denial risk is primarily tied to failure to follow plan routing and authorization rules: notably, not obtaining prior coverage authorization for breast pumps (DME) will result in noncoverage. Additionally, services billed outside the preventive/well‑visit diagnosis context may not receive $0 cost‑sharing.

Failure to obtain prior authorization for lactation equipment = likely denial/noncoverage.
Preventive services not billed with a routine/well‑woman diagnosis code may not be processed as $0 preventive benefits.

Note

No Other Explicit Provider Actions in This Section

No explicit additional provider actions (e.g., step therapy rules or other plan‑specific prior authorization requirements) are stated in this section beyond the breast pump/DME authorization and correct preventive billing context. Verify plan‑specific requirements if uncertain.

No step therapy rules are described in these source chunks.
No other specific prior authorization triggers are listed here; confirm with the payer or vendor for service‑specific rules.

Background and Scope

This document summarizes multiple USPSTF Grade A and Grade B recommendations across preventive topics — screenings (e.g., cervical, colorectal, lung, diabetes, STI screening), counseling (e.g., tobacco cessation, obesity prevention, lactation support), and selected preventive medications (e.g., aspirin for preeclampsia prevention, statins for primary prevention). For many USPSTF and WPSI/HHS-recommended services the payer indicates in-network coverage with $0 cost-sharing when services are billed as preventive or as part of an appropriate visit (annual wellness, prenatal, or well-woman visit).

Definitions and USPSTF Grade Meanings

USPSTF Grade A definition

USPSTF Grade A definitionThe USPSTF recommends the service. There is a high certainty that the net benefit is substantial.

UseIndicates services the Task Force strongly recommends; used to identify covered preventive services

Coverage implicationMany Grade A services are covered at $0 in-network when billed as preventive

USPSTF Grade B definition

USPSTF Grade B definitionThe USPSTF recommends the service. There is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

UseIndicates services the Task Force recommends; used to identify covered preventive services with criteria

Coverage implicationMany Grade B services are covered at $0 in-network when billed as preventive

USPSTF Grade A/B summary

Combined meaningGrade A: recommended with high certainty the net benefit is substantial; Grade B: recommended with high/moderate certainty the net benefit is moderate to substantial.

Policy useGrades A and B are used to identify preventive services the payer covers in-network at $0 when billed appropriately

ReferenceDefinitions sourced from USPSTF grade descriptions

Grade A/B recommendations

Grading contextUSPSTF Grade A and B indicate high or moderate certainty of substantial/moderate net benefit and guide which preventive services are recommended

ApplicationUsed in this policy to determine coverage and $0 cost-sharing for in-network preventive services

ExamplesIncludes screenings such as cervical cancer, lung cancer (Grade B), and others referenced in the document

Well-woman visit / routine diagnosis

DefinitionA preventive care visit context used to bill many services so they qualify for $0 cost-sharing under these guidelines.

Examples of visit typesAnnual wellness exam, prenatal care, well-child exam, well-woman visit

Billing requirementServices must be billed with a routine/well-woman diagnosis code to be covered at $0

Policy Summary

PayerFlorida Blue

PolicyUSPSTF Grade A & B Preventive Services Coverage (In-Network)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill preventive services with a routine/well‑woman or preventive diagnosis code and obtain prior authorization for breast pumps through the preferred DME vendor to secure coverage at $0.

SourceLink

On This Page

infants/children starting at tooth eruption; supplements start at 6 months

risk-based; pregnancy = all

initial within 1 year postpartum; repeat >= every 3 years for 10 years if negative

Statins for primary CVD prevention: Adults 40-75 without CVD, with ≥1 risk factor (dyslipidemia, diabetes, hypertension, smoking) and 10-year CVD risk ≥10% should use low-to-moderate dose statin; refer to preventive medicines list for coverage details.age 40-75 with risk factors and 10-yr risk ≥10%

chunks 18,50

Tobacco cessation interventions: Advise all adults and pregnant women about tobacco cessation; provide behavioral interventions and FDA‑approved pharmacotherapy for nonpregnant adults; covered at $0 and pharmacotherapy covered with prescription per preventive medicines list.adults; pregnant women receive counseling

chunk 19

Falls prevention (older adults): Offer exercise interventions to prevent falls in community-dwelling adults ≥65 at increased fall risk; covered at $0 as part of annual wellness exam.age ≥65 with increased risk

chunk 9

Osteoporosis screening (women): Bone measurement screening in postmenopausal women <65 at increased risk and all women ≥65 to prevent fractures; covered at $0 as part of annual wellness exam.postmenopausal women <65 at increased risk; women ≥65

chunk 46

Obesity screening and interventions: Screen adults and children/adolescents (≥6 yrs) for obesity; offer or refer to intensive multicomponent behavioral interventions when indicated (adults BMI ≥30). Covered at $0 as part of wellness visit.adults BMI ≥30; children ≥6 yrs with obesity

chunks 14,15

All adolescent and adult women starting at age 15 should have HIV screening at least once; repeat testing and rapid testing in pregnancy based on risk; covered at $0 when billed as routine/well-woman.

start age 15; repeat per risk

Contraceptive services: Access to a wide range of contraceptives including surgical sterilization, implants, copper and progestin IUDs, injectables, oral contraceptives, patch, ring, barrier methods, emergency contraception (levonorgestrel and ulipristal) and other FDA-approved methods; includes counseling, supply, follow-up and postpartum provision. Covered at $0 in-network when billed with routine diagnosis.

chunks 24,58

Lactation support and equipment: Comprehensive lactation support, counseling and supplies (e.g., double electric breast pumps) during prenatal, perinatal and postpartum periods. Equipment must be obtained through preferred DME vendor, limited to one manual or electric pump per pregnancy and prior authorization required for coverage.one pump per pregnancy

chunks 25,59

Postpartum diabetes screening after GDM: Initial screening within first year postpartum (can be 4-6 weeks); if negative, repeat at least every 3 years for 10 years; confirmatory testing required for positive results. Covered at $0 when billed with routine/well-woman diagnosis.initial within 1 year; repeat >= every 3 years for 10 years if negative

chunk 61

Other screenings and counseling: Annual screening for urinary incontinence, anxiety screening (including pregnant/postpartum), IPV screening at least annually, obesity prevention counseling for midlife women, and related services are covered at $0 when billed with a routine/well-woman diagnosis code.ages/intervals as specified per service

chunks 55-62

Billing requirement note: To obtain $0 cost-sharing for these preventive and WPSI services, providers must bill with the appropriate routine/preventive or well-woman diagnosis codes (e.g., as part of an annual wellness or prenatal visit).

chunks 51,55

OpenPayer

USPSTF Grade A & B Preventive Services Coverage (In-Network)

Coverage Criteria for USPSTF Grade A & B Preventive Services

Coding and Billing References

Provider Billing, Authorization, and Documentation Actions

Background and Scope

Definitions and USPSTF Grade Meanings

Revision History