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