Covered preventive services and general adjudication rules. Documented preventive services are covered with no member cost-sharing when rendered in-network and billed correctly; diagnostic uses are adjudicated under non-preventive benefits. Certain items require RX coverage or may be excluded by the member Certificate of Coverage.
Covered preventive services are payable with no member cost-sharing when: billed by an in-network provider and the service is a preventive service as identified in this policy and supported by applicable diagnosis codes in the primary position. (See: preventive services lists and coding grids.)
When a service is performed and appropriately reported as preventive screening it will be adjudicated under the Preventive Care Services benefit; when performed for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefit.
Preventive services identified in this policy are based on USPSTF, Bright Futures, AAP, CDC, and HRSA recommendations; employer groups with 'grandfathered' status may be exempt from certain provisions.
Before applying preventative coverage, check the member's Evidence of Coverage (EOC), Schedule of Benefits (SOB), and RX coverage for plan-specific limits or exclusions.
Items contingent on RX coverage (for example: aspirin for pre-eclampsia prevention after 12 weeks for high-risk pregnant persons, prescription smoking cessation products, contraceptive drugs and devices, statin drugs for prevention) are covered only if the member has RX coverage; quantity limits and prior authorization (where specified) may apply.
Preventive immunizations are covered when they meet: FDA approval and explicit ACIP recommendations published in the MMWR; implementation will typically occur within 60 days after MMWR publication. Immunizations not excluded by the Certificate of Coverage are considered covered when these conditions are satisfied.
Immunization administration (including codes for administration and for in-home administration) is covered as preventive when billed appropriately (see administration CPT/HCPCS and G-codes listed).
Specific preventive services have code-, age-, frequency-, and setting-based conditions noted (examples: AAA screening once per lifetime for men 65-75 with prior smoking history; colonoscopy preventive benefit excludes inpatient and ER settings; Cologuard covered ages 45-75 once every 3 years; certain immunizations have age-based coverage limits such as Zostavax 90736 limited to age 18+ and Cologuard/colonoscopy age ranges).
Certain vaccine products and monoclonal antibodies (RSV products, PCV20, RSV preF, Shingrix, COVID-19 vaccines, influenza preparations, hepatitis B formulations, etc.) are listed with product-specific CPT/HCPCS and age/risk notes and are covered per routine or risk-based recommendations when billed with appropriate diagnosis codes (ICD-10 Z23 for immunizations).
Billing expectations: all diagnosis codes for preventive, screening, counseling, or wellness should be billed in the primary position. Use the specified screening colonoscopy CPT when billing screening colonoscopy (00812 for screening; 00811 when screening becomes diagnostic).
Provider must observe listed prior authorization requirements where indicated (e.g., J0738 and J0752 under HIV Screening/HIV Prep; prior auth for certain injectable products per comments).
Coverage exclusions and plan limits: an immunization is considered covered only if it does not fall under an exclusion in the Certificate of Coverage; if the member's Certificate of Coverage excludes a vaccine despite external recommendations, the preventive benefit will not apply.
Operational notes: bowel preparations (PEG electrolyte generics) are covered in full for members aged 45-75 for colonoscopy prep; virtual CT colonography is covered when medically necessary; home vaccine administration is reportable once per home per date of service when applicable.
No explicit 'not medically necessary' criteria were provided in the excerpt; downstream confirmation is required to identify any additional medical necessity/exclusion criteria.
Refer to the Preventive Care Services Grid and immunizations lists for specific CPT/HCPCS/ICD-10 mappings, age limits, product names, administration codes, and frequency constraints (see publication history for updates).