CurrentHighmark Blueshield NenyPolicy N/A

Well-woman preventive services and contraceptive coverage

Defines coverage and clinical guidance for well-woman visits, preventive counseling and screening (including STI/HIV, HPV, breastfeeding support, gestational and postpartum diabetes screening, urinary incontinence, anxiety, nutritional counseling) and FDA-approved contraceptive methods and supplies for Highmark members in New York.

Policy Summary

PayerHighmark Blueshield Neny

PolicyWell-woman preventive services and contraceptive coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a prescription for breast pump DME and verify member eligibility and benefits at each visit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 4wellness visits annually (women)

1 per pregnancybreast pump covered

up to 2STI/HIV counseling

24–28 wkgestational diabetes timing

every 3 yrs

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Coverage and Clinical Criteria

Breastfeeding support

Covered breastfeeding/lactation support and supplies as part of preventive services.

ALL of the following

Breastfeeding counseling: Counseling for breastfeeding provided as preventive service with appropriate CPT codes (e.g., 99401–99403 or equivalent) when accompanied by pregnancy or routine preventive diagnosis.
Breastfeeding supplies: Coverage includes comprehensive lactation support services and breastfeeding equipment and supplies without cost-sharing for the duration of breastfeeding per New York State requirements.
Breast pump coverage: Coverage includes rental or purchase of one breast pump per pregnancy in conjunction with childbirth; breast pumps are treated as DME and require a prescription. Covered pump HCPCS codes include manual E0602 and electric E0603; supplies include A4281–A4287 (A4287 effective 1/1/2024).
Operational note: Providers should submit prescription for breast pump and bill appropriate DME/HCPCS codes. Verify member eligibility and benefits at time of service via Availity or 270/271 eligibility inquiry.

Billing Codes and Coding Guidance

Preventive visit and counseling CPT/HCPCSCPT | HCPCSCovered

99201-99215	E&M procedure codes for initial visit to determine pregnancy when accompanied by specified diagnosis edits
G0445	STI counseling
99401, 99402, 99403, 99404	HIV counseling

Gestational diabetes screening CPT codesCPTCovered

82947, 82950, 82951, 82952, 83036

Glucose screening CPT codes

Relevant ICD-10 diagnosis codesICD-10

Z86.32, Z87.59

History of gestational diabetes / related diagnosis codes used with postpartum screening

Breast pump and supply codesHCPCSCovered

E0602	Manual breast pump (DME)
E0603	Electric breast pump (DME)
A4281	Breast pump supply
A4282	Breast pump supply
A4283	Breast pump supply
A4284	Breast pump supply
A4285	Breast pump supply
A4286	Breast pump supply
A4287	Breast pump supply (effective 1/1/2024)

HPV screening CPT/HCPCSCPT | HCPCSCovered

87623, 87624, 87625

HPV screening test codes

Contraception app reimbursementmixedCovered

contraception app (no code)

FDA-approved contraception apps reimbursable via paper claim with prescription (no specific CPT/HCPCS listed)

Provider Responsibilities and Billing Notes

Denial Risk

Verify Member Eligibility and Benefits

Providers should always check the Availity Eligibility and Benefits function or utilize the ASC X12 270/271 Eligibility Benefits Inquiry and Response transactions each time a member presents for service. Failure to obtain or check member eligibility and benefits at each visit may result in benefit denial or incorrect claims processing.

Check eligibility and benefits at each member visit (Availity or ASC X12 270/271).
Risk: Not checking eligibility can lead to denied or misprocessed claims.

Step Therapy

No Fail‑First Required for Contraceptives

An initial 'Fail First' (step therapy) is not required for contraceptive drugs. Providers may request a formulary exception based on provider-determined medical necessity. If a nonformulary contraceptive drug is medically necessary, the provider should complete the online exception request form; documenting a prior failed formulary drug is optional but not required for approval.

No initial fail-first required for contraceptive drugs.

Background and Rationale

Well-woman visits deliver age- and developmentally-appropriate preventive services, including counseling and screening for sexually transmitted infections and HIV, cervical and HPV screening, breastfeeding support, and screening for gestational and postpartum diabetes, urinary incontinence, anxiety, and nutritional concerns. These services are furnished as part of routine or pregnancy-appropriate visits and aligned with recommended timing and frequency (for example, gestational diabetes screening at the first prenatal visit or at 24–28 weeks, and postpartum follow-up screening for women with prior gestational diabetes).

Definitions and Products

Over-the-counter contraceptive products (HRSA-supported guidelines / FDA-approved items)

DefinitionProducts provided for in comprehensive HRSA-supported guidelines that are FDA-approved and may be covered when prescribed or otherwise authorized

ScopeIncludes FDA‑approved contraceptive methods, drugs, devices, and other products; emergency contraception when prescribed or lawfully provided over‑the‑counter

Coverage conditionCovered when prescribed or otherwise authorized under State or Federal law; coverage required even if prescription drugs are not otherwise covered under the policy or contract

Religious employer optionGroups meeting the definition of a religious employer may purchase a stand‑alone contraceptive coverage rider instead of receiving coverage through the plan

Urinary incontinence

Definition

Revision History

2024-01-01code update

Added HCPCS supply code A4287 to the list of covered breast pump supplies effective 1/1/2024.

2023-01-01guideline update

Clarified gestational diabetes screening timing and postpartum rescreening recommendations; added nutritional counseling guidance (effective 1/1/2023).

2021-01-01guideline update

Added recommendation to screen adolescent and adult women, including pregnant or postpartum, for anxiety per the Women’s Preventive Services Initiative (effective 1/1/2021).