Preventive Benefits

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 for a non-preventive care service or diagnosis code will be subject to In-Network Deductible and Co-Insurance.

Out-of-Network Coverage
Preventive care services received from Out-of-Network providers are subject to the Out-of-Network Deductible, Co-Insurance and balance billing. Claims for preventive care services submitted by an Out-of-Network provider for a non-preventive care service or diagnosis code will be subject to Out-of-Network Deductibles and Co-Insurance.

Covered Preventive Care Services
Evidence based items & services that hold a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.healthcare.gov/coverage/preventive-care-benefits/ Link

Examples of Covered Preventive Care Services:
Abdominal Aortic Aneurysm Screenings
Blood Pressure Screenings
Bone Density Screenings
Cervical Screenings
Colonoscopy Screenings (Including Digital Imaging)
Diabetic Screenings
Flu Vaccines (+ H1N1)
Immunizations
Mammogram Screenings (Including Digital Imaging)
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.
www.cdc.gov/vaccines/schedules/index.html/ Link

Evidenced Informed Preventive Care & Screenings for Infants, Children & Adolescents
As provided for in the comprehensive guidelines of the Health Resources & Services Administration (“HRSA”).
www.aap.org/en-us/professional-resources/practicesupport/Pages/PeriodicitySchedule.aspx Link

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 Link

Breastfeeding Counseling, Support Services & Supplies
Benefits provided for Breastfeeding Counseling & Support Services received through a provider specializing in the care of Pregnant & Postpartum Women, and also include:
》Manual Breast Pumps, Accessories & Supplies
   》Limit of 2 units per plan year
   》Available for free from ConnectDME
   》Or other 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 for free from ConnectDME
   》Or other In-Network providers
 》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 ConnectDME
   》Rented equipment be returned at the end of the rental coverage period