Preventive Care Services

In-Network Coverage
Preventive Care Services received from In-Network Providers and BlueCard PPO Providers are not subject to Deductible, Co-pay, Co-Insurance or dollar maximums. Claims for Preventive Care Services submitted by an In-Network or BlueCard PPO Provider with a Non-Preventive Service or Diagnosis Code will be subject to In-Network Co-Pays, Deductibles and Co-Insurance.
Out-of-Network Coverage
Preventive Care Services received from Providers who are not In-Network Providers or BlueCard PPO Providers are subject to Out-of-Network Deductible, Co-Insurance and/or balance billing. Claims for Preventive Care Services submitted by an Out-of-Network Provider with a Non-Preventive Service or Diagnosis Code will be subject to Out-of-Network Deductibles and Co-Insurance.
Covered Preventive Care Services
Evidence Based Items & Services
Services that hold a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
https://www.healthcare.gov/coverage/preventive-care-benefits/
Examples of Covered Preventive Care Services:
   》Abdominal Aortic Aneurysm Screenings
   》Blood Pressure Screenings
   》Bone Density Screenings
   》Cervical Screenings
   》Cholesterol Screenings
   》Colonoscopy Screenings (Including Digital Imaging)
   》Diabetic Screenings
   》Flu Vaccines (+ H1N1)
   》Immunizations
   》Mammogram Screenings (Including Digital Imaging)
   》Obesity Screenings & Counseling
   》Prostate (PSA) Screenings
   》Tobacco Use Screenings & Counseling
Routine Immunizations for Children, Adolescents & Adults
As recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control & Prevention.
http://www.cdc.gov/vaccines/schedules/index.html
Evidenced Informed Preventive Care & Screenings for Infants, Children & Adolescents
As provided for in the comprehensive guidelines of the Health Resources & Services Administration (“HRSA”).
https://www.aap.org/en-us/professional-resources/practicesupport/Pages/PeriodicitySchedule.aspx
Evidence Based Preventive Care & Screenings for Women
As provided for in the comprehensive guidelines of the Health Resources & Services Administration (HRSA).
www.hrsa.gov/womensguidelines/index.html
Breastfeeding Counseling, Support Services & Supplies
Benefits provided for Breastfeeding Counseling & Support Services received through a Providers specializing in the care of Pregnant & Postpartum Women, and also include:
   》 Manual Breast Pumps, Accessories & Supplies Covered in full for the Rental of, or at the Health Plan’s discretion, the purchase of. Limit of 2 units per plan year. Available from a contracted Durable Medical Equipment supplier, retail suppliers, In-Network or Out-of-Network Providers.
   》 Electric Breast Pumps, Accessories & Supplies Covered in full up to a maximum of $150 per unit. Limit of 2 units per plan year. Available only from In-Network Providers or contracted Durable Medical Equipment suppliers.
   》 Hospital Grade Breast Pumps, Accessories & Supplies Available through rental agreements. Covered in full for up to 12-months of rental or once the Health Plan has paid $1,000 in rental fees, whichever occurs first. Available only from contracted Durable Medical Equipment suppliers. Rented equipment be returned to the Durable Medical Equipment supplier at the end of the rental coverage period.