Preventive services – Adult

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

No prior authorization is required for most Preventive Services.
Prior authorization is required for BRCA testing. See related content at right for link to policy.

Routine Preventive services are routine healthcare services that include screenings, check-ups and counseling to prevent illness, disease, or other health problems before symptoms occur.

• These services are covered at your preventive benefit level.
• These services covered as routine preventive services are derived from the US Preventive Services Task Force, A and B Recommendations.

To view preventive care guidelines based on age and gender, please see Related content at right.

Indications that are covered

The following lists, though not all inclusive, detail services eligible for coverage under the Preventive Services Benefit. Services not specifically addressed in this policy may be covered according to your plan documents.

During a routine preventive office visit

Screenings and assessments for:

• Alcohol, drug and tobacco use
• Hepatitis B virus in non-pregnant adolescents and adults at high risk for infection
• Hepatitis C virus (HCV) infection in persons at high risk for infection
• One-time screening for HCV infection to adults born between 1945 and 1965.
• Blood pressure
• Depression
• Diabetes
• Obesity
• Hearing (subjective questionnaire and counseling)
• Vision (objective Snellen chart testing)

Counseling from a primary medical provider for:

• Alcohol, and drug misuse
• Aspirin for men and women of certain ages and cardiovascular factors
• Breast and ovarian cancer risk assessment, including counseling about genetic testing for women at higher risk (BRCA)
• Breast cancer chemoprevention counseling (for women at higher risk)
• Diet (for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease)
• Folic acid supplements (for women of child-bearing ages)
• Obesity - see related content at right for link to intensive dietary counseling for obesity for adults policy
• Sexually transmitted infection (STI) prevention (for adults at higher risk)
• Skin cancer prevention behavioral counseling for young adults to 24 years of age who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk of skin cancer. This does not include examinations, testing, or treatment.
• Tobacco use (including programs to help you stop using tobacco)
• Intimate partner violence for women of childbearing age, and refer or provide intervention for women who screen positive.

Immunizations:

Doses, recommended ages, and recommended populations vary. See related content at the right for link to CoOportunity Health Immunization policy.

• Tetanus, Diphtheria, Pertussis (TDaP)
• Hepatitis A, Hepatitis B
• Herpes zoster (shingles)
• Human papilloma virus (HPV)
• Influenza (flu)
• Measles, mumps, rubella (MMR)
• Meningococcal (meningitis)
• Pneumococcal (pneumonia)
• Varicella (chicken pox)

Medications

These medications are covered with a prescription from your medical provider:

• Aspirin to prevent cardiovascular disease for men ages 45-79 and women 55-79
• Folic acid supplementation for women of childbearing age planning or capable of pregnancy
• Vitamin D supplementation to prevent falls in community dwelling adults age 65 and over who are at increased risk for falls
• Smoking Cessation medications

Additional covered testing/counseling that may be ordered during a routine, preventive office visit but done separately:

• One-time ultrasound (for men ages 65-75 who have ever smoked) for abdominal aortic aneurysm
• One time screening for hepatitis C virus (HCV) infection for adults born between 1945 and 1965
• Pap test for cervical cancer
• Chlamydia infection (for younger women and other women at higher risk)
• Cholesterol (for adults of certain ages or at higher risk)
• Colonoscopy, sigmoidoscopy, or fecal occult blood testing (for adults over 50) for colon cancer
• Gonorrhea (for all women at higher risk)
• HIV (for all adults at higher risk)
• Mammography (every 1 to 2 years for women over 40) for breast cancer
• Osteoporosis (for women over age 60 depending on risk factors)
• Syphilis (for all adults at higher risk)
• Type 2 diabetes (for adults with high blood pressure)
• Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Note: Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians

Additional covered services for pregnant women

• Anemia screenings
• Bacteriuria, urinary tract, HIV, syphilis and chlamydial infection screenings
• Rh incompatibility screening, with follow-up testing for women at higher risk
• Hepatitis B counseling (at the first prenatal visit)
• Breast feeding counseling, including lactation consultants, and interventions  to support and promote breast feeding after delivery. (See related content at right for link to Breast Pump policy).
• Tobacco use counseling

Additional covered services for women

• FDA approved forms of contraception.
• Standard and FDA approved sterilization procedures. (See related content at right for link to Sterilization Policy)
• BRCA testing for genetic predisposition for ovarian and breast cancer when coverage criteria are met. (See related content at right for link to policy).

Services that are Not Covered

The following list, though not all inclusive, details services not eligible for coverage at any benefit level:

1. Over the counter tests not ordered by your primary medical provider.
2. Any supplements recommended at a preventive care visit except those listed in the Medication Section above.
3. Preventive services or screenings including, but not limited to exams, lab tests, x-rays received from or ordered by:
   1. Non-contracted, mobile, outpatient screening entities
   2. A non-medical care provider (e.g. naturopath)

The following list, though not all inclusive, details services not eligible for coverage under the Preventive Services benefit because they are considered diagnostic:

• Genetic testing other than BRCA when indicated. (See related content at right for link to policy)
• Referrals to specialists for evaluation of findings during routine preventive screening.

Diagnostic services are services used to help your provider understand your symptoms, diagnose your illness, and decide what treatment you need. They may be the same tests that are listed as preventive services, but they are being used as diagnostic services. These services are not preventive if you receive them as part of a visit to diagnose, monitor an established condition, or treat an illness or injury. When that occurs, your standard deductibles, co-pays or coinsurance apply.

Routine Preventive services are routine healthcare services that include screenings, check-ups and counseling to prevent illness, disease, or other health problems before symptoms occur.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Portions of the contents of these coverage criteria are taken directly from the U.S. Preventative Services Task Force website.

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.