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/

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/

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

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

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 or Out-of-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
		Only Available and for free from ConnectDME
		Rented equipment be returned at the end of the rental coverage period