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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 benefits under all of its medical plans at 100% for in network preventive care following U.S. Preventive Services Task Force (USPSTF) guidelines.

Preventive Health Benefits 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 50 years and older Fecal occult blood testing – annually
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 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
(effective 7/1/17)
Medical nutritional counseling Two visits per calendar year with diagnosis of obesity
Sexually transmitted infections (STIs) screening and prevention counseling Counseling is one per calendar year
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
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
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
Pregnant Women
Prenatal care First visit to determine pregnancy
Anemia screening  
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 DMEnsion; CDHP members contact your medical plan
Gestational diabetes screening  
Hepatitis B screening  
HIV screening  
Rh Incompatibility screening  
Prenatal/postpartum depression screening  
Urinary tract or other infection screening At 12 to 16 weeks gestation or at first prenatal visit, if later
Children
Well child visits One per calendar year for ages 18 years and younger
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 One per calendar year
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
  • 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 18 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 One per calendar year
Sexually transmitted infections (STIs) prevention counseling and screening One per calendar year
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 for the prevention of cardiovascular disease – adults age 50 to 59
  • 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 50 through 74
  • Contraceptives (for females) including emergency contraceptives and over-the-counter contraceptive products (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
  • Iron supplements for children who are at increased risk for iron deficiency anemia – children age 6 through 11 months
  • Medications for risk reduction of primary breast cancer in women age 35 and older
  • Oral fluoride for preschool children older than six months to five years of age without fluoride in their water
  • Vitamin D supplements to help prevent falls in adults age 65 years or older who are at increased risk for falls
  • Tobacco cessation and nicotine replacement products – prescription drug coverage is for the generic form of Zyban or brand-name Chantix (limited to a maximum of 168-day supply)
NOTE: These guidelines are subject to change.