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Active Members Information: Preventive Benefits

The Patient Protection and Affordable Care Act (PPACA) requires plans to cover network preventive care services according to guidelines established by various sources. Effective July 1, 2014, the PEBTF provides coverage for the following preventive care benefits under all of its medical plans at 100% for in network preventive care.

This chart outlines the preventive care benefits for adults, women, including pregnant women, and children.

Preventative care follows:

USPSTF: Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).

ACIP (CDC): Immunizations for routine use in children, adolescents and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

HRSA: With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines support by the Health Resources and Services Administration (HRSA)

HRSA: With respect to women, to the extent not described above, evidence informed preventive care and screenings provided for in binding comprehensive health plan coverage guidelines supported by the HRSA.

These guidelines are subject to change.

Preventive Care Services	Frequency/Comments
Adults
Abdominal aortic aneurysm screening	One time screening for men ages 65 to 75 years who have ever smoked
Adult routine physical exams and preventive care (age 19 and over)	One per calendar year
Alcohol screening and counseling	One per calendar year; any future treatment must be obtained under the mental health and substance abuse benefit
Blood pressure screening	One per calendar year
Cholesterol screening	One per calendar year
Colorectal cancer screening – for adults 45 years and older	Fecal occult blood testing or fecal immunochemical test (FIT) – annually Cologuard - every 3 years CT colonography - every 5 years Sigmoidoscopy – every 5 years Screening colonoscopy – every 10 years
Depression screening	One per calendar year; any future treatment must be obtained under the mental health and substance abuse benefit
Glucose screening	One per calendar year
Healthy Diet Counseling – for adults with known risk factors for cardiovascular disease in accordance with USPSTF guidelines	Two visits per calendar year (care may be delivered by your PCP or by referral to other specialists such as nutritionists or dietitians)
Hepatitis B virus (HBV) infection screening	In adults at high risk of infection
Hepatitis C (HCV) virus infection screening	In adults at high risk for infection and a one-time screening for adults born between 1945 and 1965
Immunizations Haemophilus influenza type B (Hib) Hepatitis A Hepatitis B Herpes Zoster (shingles)   - Shingrix – age 50 and older   - Zostavax – age 60 and older Human Papillomavirus (HPV) – females & males to age 26 Influenza (flu) Measles, Mumps, Rubella (MMR) Meningococcal Pneumococcal Tetanus, diphtheria, pertussis (Td/Tdap) Varicella (chickenpox) Immunizations that combine two or more component immunizations to the extent the component immunizations are covered under the Plan	Doses, recommended ages and recommended populations vary. All recommended routine immunizations are covered at no cost to the member. Vaccines are recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)
Latent turberculosis infection (LTBI) screening in asymptomatic adults at increased risk (age 18 and older)	One per calendar year
Medical nutritional counseling	Two visits per calendar year with diagnosis of obesity
Prostate Specific Antigen (PSA) testing for prostate cancer screening (Effective 4/1/2023)	Between ages 50 and 70 years; every other year
Sexually transmitted infections (STIs) screening and prevention counseling	Counseling is one per calendar year, screening in accordance with USPSTF guidelines
Tobacco use counseling and interventions	Prescription tobacco cessation products are covered under the prescription drug plan
Women
Well Woman visits	Annual, though 2 OB/GYN and 2 physical exams may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs and other risk factors
Breast cancer chemoprevention counseling	For women at higher risk; does not include the chemoprevention medications under the prescription drug plan
Breast cancer genetic test counseling (BRCA)	For women at higher risk
Breast cancer mammography screenings	One per calendar year for women age 40 and older (includes coverage for 3-D mammograms)
Cervical cancer screenings	Cytology (pap smear) one per calendar year
Contraception methods counseling All Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity.	Counseling is included in physical exam Prescription drugs and OTC products (sponges, spermicides) are covered under the prescription drug plan All contraceptive products require a prescription
Osteoporosis screening – bone mineral density screening	Age 65 years and older
Screening and counseling for interpersonal and domestic violence	Included in physical exam
STIs counseling and screening	Counseling is two per calendar year; screening in accordance with USPSTF guidelines
Pregnant Women
Prenatal care	First visit to determine pregnancy
Anemia screening	Screening in accordance with USPSTF guidelines
Breastfeeding support, supplies and counseling by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment. Certain breast pumps and supplies are covered for post-partum women	You must obtain the breast pumps under the Durable Medical Equipment benefit provided by your medical plan.
Gestational diabetes screening	Screening in accordance with USPSTF guidelines
Hepatitis B screening	Screening in accordance with USPSTF guidelines
HIV screening	Screening in accordance with USPSTF guidelines
Rh Incompatibility screening	Screening in accordance with USPSTF guidelines
Prenatal/postpartum depression screening	Screening in accordance with USPSTF guidelines
Urinary tract or other infection screening	At 12 to 16 weeks gestation or at first prenatal visit, if later
Children
Well child visits	Unlimited for children under age 3; one per calendar year for ages 3 to 18 years
Alcohol screening and counseling	For ages 7 to 18; one per calendar year; any future treatment must be obtained under the mental health and substance abuse benefit
Blood pressure screening	Included in well child visits
Cervical cancer screening	For sexually active females
Cholesterol screening	One per calendar year for children ages 2 through 18
Depression screening	One per calendar year; any future treatment must be obtained under the mental health and substance abuse benefit
Developmental/Behavioral screening	One per calendar year
Glucose screening	One per calendar year for children ages 2 through 18
Hearing screening	For all newborns
Height, weight and body mass index measurements	One per calendar year
Hematocrit or hemoglobin screening	One per calendar year
Immunizations Dengue (Dengvaxia) (effective 12/1/2022) Diphtheria/Tetanus/Pertussis (DTaP), Tetanus/Diphtheria/Pertussis (Tdap) or Tetanus/Diphtheria (Td) Haemophilus influenza type b (Hib) Hepatitis A Hepatitis B Human Papillomavirus (HPV) – for females and males ages 9 to 21 Influenza (members age 9 and older may also receive the vaccine under the Prescription Drug Plan – see the Prescription Drug Plan section for more information Measles/Mumps/Rubella (MMR) Meningococcal (MCV4) Pneumococcal (PCV) Polio (IVP) Rotavirus Varicella (Chickenpox) Immunizations that combine two or more component immunizations to the extent the component immunizations are covered under the Plan	Pediatric immunizations are covered for Members and Dependents up to age 21 at no cost Vaccines are recommended by the Centers for Disease Control and Prevention (CDC)
Lead screening	Two per calendar year
Medical nutritional counseling	Two per calendar year with diagnosis of obesity
Medical history	Included in well child visits
Sexually transmitted infections (STIs) prevention counseling and screening	One per calender year; screening in accordance with USPSTF guidelines
Tobacco use counseling and interventions	For ages 7 to 18 years
Tuberculin test
Vision screening	One per calendar year

Prescription Drug Plan

Preventive Care Covered Medications – No Copayment

For Members Enrolled in Medical Only: If you and your eligible Dependents are enrolled for coverage in a Medical Plan Option but not in the prescription drug Supplemental Benefits Option, your Medical Plan Option shall be supplemented to provide you and your eligible dependents with coverage, without cost-sharing, for the preventive prescription drugs listed below. You will receive a CVS Caremark Preventive Drug Plan ID card which you should use at a CVS Pharmacy to obtain preventive prescription drugs without any deductible, copayments or coinsurance. Please refer to the list of covered medications below.

For Members Enrolled in the PEBTF Prescription Drug Plan: If you are enrolled in the prescription drug Supplemental Benefits Option, the plan offers coverage for preventive care prescription drugs.

The following medications are covered at no cost with a prescription from your doctor:

• Aspirin to help prevent illness and death from preeclampsia in women age 12 and older after 12 weeks of pregnancy who are at high risk for the condition
• Bowel preparation medications for screening colorectal cancer for adults age 45 through 74
• Contraceptives (for females) including emergency contraceptives and over-the-counter contraceptive products (condoms, sponges, spermicides)
• Folic acid daily supplement for women only age 55 or younger who are planning to become pregnant or are able to become pregnant
• Medications for risk reduction of primary breast cancer in women age 35 and older who are at risk
• Oral fluoride for preschool children older than six months to five years of age without fluoride in their water
• Tobacco cessation and nicotine replacement products – prescription drug coverage is for the generic form of Zyban or brand-name Chantix and nicotine replacment products (limited to a maximum of 168-day supply)
• Statins for the primary prevention of cardiovascular disease in a patient 40 to 75 years of age, who has one or more cardiovascular risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking), and an estimated 10-year risk of a cardiovascular event of 10 percent or greater (effective 8/1/2023)
• Antiretroviral therapy for pre-exposure prevention of Human Immunodeficiency Virus (HIV) infection in people who are at an increased risk

Remember that a prescription is required for you to obtain reimbursement for any of these preventive prescription drugs, even those that are available over the counter.

NOTE: These guidelines are subject to change.