Highmark Delaware women’s preventive coverage

Coverage Criteria

Well-woman visits

Covered preventive services and visit frequency

Well-woman visit coverage: Up to four wellness visits annually for women: two visits with a Primary Care Physician (PCP) and two visits with an Obstetrician/Gynecologist when billed with a routine diagnosis.up to 4 visits/year

Initial visit to determine pregnancy defined as E&M procedure codes 99201-99215 when accompanied by amenorrhea (N91.2) or pregnancy diagnosis.

HIV/STI Counseling and Screening

HIV and STI screening/counseling

HIV screening and counseling: Counseling for sexually active women; risk assessment and prevention education beginning at age 13; HIV screening at least once in a lifetime for ages 15 and older; screen all pregnant women at initiation of prenatal care with rescreening during pregnancy based on risk factors.age-based screening

Up to two counseling sessions per year with codes 99401–99404 or G0445 when accompanied by appropriate routine diagnoses.

Breastfeeding counseling and supplies

Breastfeeding support

Lactation support and equipment: Comprehensive lactation support services including breastfeeding counseling and breastfeeding equipment and supplies without cost-sharing for the duration of breastfeeding; coverage includes renting or purchasing one breast pump per pregnancy in conjunction with childbirth.one pump per pregnancy

Breast pumps are DME requiring a prescription; covered HCPCS include E0602 (manual), E0603 (electric) and supplies A4281–A4286 (A4287 effective 1/1/2024).

Contraceptive and sterilization services

Contraception coverage

Contraceptive coverage: Coverage is required for FDA‑approved contraceptive methods including drugs, devices, sterilization procedures, and over‑the‑counter contraceptive products as authorized by law; emergency contraception is covered when prescribed or lawfully provided over‑the‑counter.no cost-sharing where applicable

Members may request coverage for an alternative version if the covered method is unavailable or medically inadvisable; groups qualifying as religious employers may elect a separate rider. Coverage applies even if prescription drugs are not otherwise covered under the policy.

Gestational and postpartum diabetes screening

Gestational diabetes screening: Screen for diabetes in pregnancy at the first prenatal visit and again at 24–28 weeks of gestation.screening at first visit and at 24-28 weeks

Use CPT screening codes 82947, 82950, 82951, 82952 or 83036 when accompanied by a pregnancy diagnosis or postpartum diagnosis and a history code Z86.32 or Z87.59 as appropriate.

Postpartum diabetes screening frequency: For women with a history of gestational diabetes and no prior diabetes diagnosis, initial postpartum testing should ideally occur within the first year (can be as early as 4–6 weeks); if initial test is negative, rescreen at least every 3 years for a minimum of 10 years; if positive, perform confirmatory diagnostic testing.rescreen every 3 years for 10 years

Coding guidance: when no pregnancy or diabetes diagnosis, use Z86.32 or Z87.59 with procedure codes; documented frequency guidance references 2 annually in coding guidance for programmatic tracking.

Behavioral health and urinary incontinence screening

Urinary incontinence and anxiety screening

Urinary incontinence screening: Screen women annually for urinary incontinence as part of the well‑woman visit; assessment should determine whether involuntary leakage occurs and whether it impacts activities and quality of life, with referral for evaluation or treatment if indicated.annual

Urinary incontinence is defined as involuntary leakage of urine (e.g., with coughing or sneezing).

Anxiety screening: Recommend screening for anxiety in adolescent and adult women, including pregnant and postpartum populations, per clinical guideline recommendations.per guideline

Recommendation from the Women’s Preventive Services Initiative as incorporated into the preventive services addendum.

Grandfathered employer group health plans may not be subject to all provisions of the Affordable Care Act. As stated in the addendum, benefits that implement PPACA-required preventive services may not apply to grandfathered plans unless the employer elects coverage. Providers and billing staff should confirm plan status and benefit applicability when scheduling or billing preventive services to determine whether cost-sharing or coverage differences apply.

Coding and Billing

Breast pump and supplies (DME and HCPCS)HCPCSCovered

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

Well-woman E&M codesCPTCovered

99201	E&M initial visit (now CPT range 99201-99215 referenced)
99202	E&M
99203	E&M
99204	E&M
99205	E&M
99211	E&M
99212	E&M
99213	E&M
99214	E&M
99215	E&M

Counseling codes (STI/HIV/breastfeeding)CPTCovered

G0445	Sexually transmitted infection (STI) counseling
99401	Preventive medicine counseling
99402	Preventive medicine counseling
99403	Preventive medicine counseling
99404	Preventive medicine counseling

Gestational and postpartum diabetes screening CPT codesCPTCovered

82947	Glucose test
82950	Glucose test variant
82951	Glucose test variant
82952	Glucose test variant
83036	Hemoglobin A1c

HPV screening CPT codesCPTCovered

87623	HPV test
87624	HPV test
87625	HPV test

ICD-10 pregnancy/diabetes history codesICD-10

Z86.32	History of gestational diabetes
Z87.59	Personal history of other endocrine, nutritional and metabolic disease

HPV screening interval — once every three years for women ages 30+ with normal cytology

Recommended intervalOnce every 3 years for women age 30 and older with normal Pap cytology

Applicable test codesCPT 87623, 87624, 87625 when accompanied by a routine diagnosis

ConditionNormal Pap cytology result required to use 3‑year interval

ScopeApplies to routine preventive HPV screening for women ≥30

Postpartum diabetes initial screening timing — ideally within first year postpartum; can be as early as 4-6 weeks postpartum

Provider Actions and Billing Rules

Prior Authorization

Contraceptive formulary exception process

Your provider may request a formulary exception (prior authorization) for a prescribed nonformulary contraceptive drug based on medical necessity by completing the online Pharmacy Prior Authorization request form. When approved, the prescribed drug will be available with a zero-dollar member cost share.

Provider completes online Pharmacy Prior Authorization / exception request form.
Approval grants the prescribed nonformulary contraceptive with $0 cost share.

Step Therapy

Contraception step therapy

Initial 'fail first' (step therapy) is not required for contraceptive drugs. A provider-determined medical necessity justification alone is sufficient when requesting an exception; the provider may note a prior formulary trial or failure but it is not required.

No initial 'fail first' required — provider medical necessity suffices.
Provider may document previous formulary trial but it is optional.

Definitions

Breastfeeding equipment (breast pumps) — classified as DME; prescription requirement; lists of HCPCS supply codes

ClassificationBreastfeeding equipment (breast pumps) are classified as Durable Medical Equipment (DME) and require a prescription

Covered device HCPCSE0602 (manual breast pump); E0603 (electric breast pump)

Covered supplies HCPCSA4281, A4282, A4283, A4284, A4285, A4286 (and A4287 effective 1/1/2024)

Benefit limitCost of renting or purchasing one breast pump per pregnancy in conjunction with childbirth

Well‑woman visit definition — preventive care visit definition, up to four annually and coding guidance

DefinitionWell‑woman visit: preventive care visit for adult women to obtain recommended age‑ and developmentally‑appropriate preventive services

Background

This addendum defines Highmark Delaware coverage for a core set of women’s preventive services including well-woman visits (up to 4 visits per year—typically two with a primary care provider and two with an OB/GYN when billed with routine diagnosis codes), HIV/STI counseling and screening (risk assessment beginning at age 13 and at least one lifetime HIV screening for ages 15+; screening in pregnancy at initiation of prenatal care with rescreening as indicated), breastfeeding support and equipment (comprehensive lactation services and coverage for rental or purchase of one breast pump per pregnancy, DME requiring a prescription, with specified HCPCS codes), contraceptive methods and sterilization services (coverage for all FDA‑approved methods without cost‑sharing and an exception process for nonformulary drugs based on provider‑documented medical necessity), and related services such as gestational and postpartum diabetes screening (screen at first prenatal visit and at 24–28 weeks; initial postpartum testing ideally within the first year, as early as 4–6 weeks) plus screening for urinary incontinence and anxiety per guideline recommendations.

OpenPayer

Women's Preventive Health Services Addendum (Preventive Services for Women)

Coverage Criteria

Coding and Billing

Provider Actions and Billing Rules

Definitions

Background