Preventative Services
Start members receive 100% of our reimbursement rate for preventative care pre-deductible. Procedures, tests, and prescriptions are considered preventative care based on these government guidelines.
Preventative Services for Adults & Children
Preventative Services for Children
- Alcohol and drug use assessment for adolescents.
- Autism screening for children at 18 and 24 months.
- Behavioral assessment for children ages: 0-11 months, 1 to 4, years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Cervical dysplasia screening for sexually active females
- Depression screening for adolescents.
- Developmental screening for children under age 3.
- Dyslipidemia screening for children at higher risk of lipid disorders ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Fluoride chemoprevention supplements for children without fluoride in their water source.
- Gonorrhea preventive medication for the eyes of all newborns.
- Hearing screening for all newborns.
- Height, weight and body mass index (BMI) measurements for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Hematocrit or hemoglobin screening for all children.
- Hemoglobinopathies or sickle cell screening for newborns.
- Hepatitis B screening for adolescents at high risk, including adolescents from countries with 2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11 – 17 years.
- HIV screening for adolescents at higher risk.
- Hypothyroidism screening for newborns.
- Lead screening for children at risk of exposure.
- Medical history for all children throughout development ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years.
- Obesity screening and counseling.
- Oral health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
- Phenylketonuria (PKU) screening for newborns.
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk.
- Tuberculin testing for children at higher risk of tuberculosis ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
- Vision screening – Basic eye exam with refraction once per year (Calendar or Plan year) – *Glasses/frames coverage is not preventative. If the member is age 18 or under we will apply up to $150 towards the deductible/MOOP for basic hardware only. Refer to the member’s Outline of Coverage*
Preventative Services for Adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked.
- Alcohol misuse screening and counseling.
- Aspirin use to prevent cardiovascular disease for men and women of certain ages.
- Blood pressure screening.
- Cholesterol screening for adults of certain ages or at higher risk.
- Colorectal cancer screening for adults ages 45 to 75.
- Depression screening
- Diabetes (Type 2) screening for adults with high blood pressure.
- Diet counseling for adults at higher risk for chronic disease.
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults at increased risk, and one time for all adults aged 18-79 years.
- HIV screening for everyone ages 15 to 65, and other ages at increased risk.
- Lung cancer screening for adults 50 – 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years.
- Obesity screening and counseling.
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk.
- Syphilis screening for persons at higher risk.
- Tobacco Use screening for all adults and cessation interventions for tobacco users.
- Vasectomy/Vasectomies for men (Effective 1/1/21 – 11/14/2021 only) benefit includes 1 follow up and 1 sperm count appointment. **On and After 11/15/2021 all Vasectomies for men, including follow up care will be subject to the member’s deductible.**
Immunizations from Birth to Age 18
Doses, recommended ages, and recommended populations vary:
- Diphtheria, Tetanus, Pertussis (Whooping Cough)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (PVU)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Pneumococcal
- Rotavirus
- Varicella (Chickenpox)
Immunizations for Adults
Doses, recommended ages, and recommended populations vary:
- Diphtheria
- Hepatitis A
- Hepatitis B
- Herpes Zoster (Shingles)
- Human Papillomavirus (HPV)
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pertussis
- Pneumococcal
- Rubella
- Tetanus
- Varicella (Chickenpox)
Preventative Services – Women & Pregnancy
Covered Preventative Services for Women
- Breast cancer genetic test counseling (BRCA) for women at higher risk. Prior Authorization is required for this to be considered preventative.
- Breast cancer mammography screenings every 1 to 2 years for women over 40 (Including 3D Mammograms)
- Breast cancer chemoprevention counseling for women at higher risk.
- Cervical cancer screening for sexually active women.
- Chlamydia infection screening for younger women and other women at higher risk.
- Domestic and interpersonal violence screening and counseling for all women.
- Gonorrhea screening for all women at higher risk.
- HIV screening and counseling for sexually active women.
- Human Papillomavirus (HPV) DNA test every 3 years for women with normal cytology results who are 30 or older.
- Osteoporosis screening for women over age 65 (DEXA Scan/Bone Density Scan is only considered preventative over the age of 65).
- Rh incompatibility screening follow-up testing for women at higher risk.
- Sexually transmitted infections counseling for sexually active women.
- Syphilis screening for women at increased risk.
- Tobacco use screening and interventions.
- Well-woman visits to get recommended services for women under 65.
Services for Women Who Are or
May Become Pregnant
- Anemia screening on a routine basis.
- Breastfeeding (Lactation) comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women. 2 Lactation support and counseling visits by a trained provider per pregnancy to ensure the successful initiation and duration of breast feeding.
- Contraception (birth control, IUD’s, etc.): Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- For IUD type contraceptives: insertion and removal is covered at 100% but if any complications happen, those may be subj to DED.
- Folic acid supplements for women who may become pregnant.
- Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.
- Gonorrhea screening for all women at higher risk.
- Hepatitis B screening for pregnant women at their first prenatal visit.
- Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening.
- Expanded tobacco intervention and counseling for pregnant tobacco users.
- Urinary tract or other infection screening.
Potential Preventative Lab work (subject to the deductible/copay depending on how it’s billed)
Warning IMPORTANT: All lab work mentioned below may be subject to the deductible/copay depending on how its billed
Laboratory Tests (18 and older) – These may be subject to the deductible/copay depending on how its billed
- Prostate Cancer Screening (PSA)
- Diabetes Screening
- Cholesterol Screening
- Gonorrhea Screening
- Human Papillomavirus (HPV) Testing (once every 3 years for women ages 30 to 65)
- Chlamydia Screening
- Human Immunodeficiency Virus (HIV) Screening
- Syphilis Screening
- Tuberculosis (TB) Testing
- Lead Screening
- BRCA 1 & 2 Testing (Requires Prior Authorization, covered once per lifetime for high-risk individuals who meet criteria)
- Hepatitis B Virus (HBV) Screening (covered for high-risk individuals who meet criteria)
- Hepatitis C Virus (HCV) Screening (once per lifetime for individuals over age 50)
Laboratory Tests (younger than 18) – These may be subject to the deductible/copay depending on how its billed
- Newborn Metabolic Screening (younger than age 1)
- Human Immunodeficiency Virus (HIV) Screening
- PKU Screening (younger than age 1)
- Thyroid (younger than age 1)
- Sickle Cell Disease Screening (younger than age 1)
- Lead Screenings
- Tuberculosis (TB) Testing
Laboratory Tests Pregnant Women – These may be subject to the deductible/copay depending on how its billed
These are specific to pregnant women. To determine which additional non-obstetrical services may be considered preventive, please refer to the Adult or Pediatric Preventive Services lists.
- Iron Deficiency Anemia Screening
- Diabetes Screening
- Urine Study to Detect Asymptomatic Bacteriuria (first prenatal visit or at 12 to 16 weeks gestation)
- Rubella Screening
- Rh(D) Incompatibility Screening
- Hepatitis B Infection Screening (at first prenatal visit)
- Gonorrhea Screening
- Chlamydia Screening
- Syphilis Screening
Pharmaceutical Preventative Services
We are only reimbursing generic medications at this time. Call our team with any questions.
Influenza (Flu) Shot
Member’s can get a flu shot at a pharmacy or doctor’s office.
1. Pharmacy
-
a. Members should be able to get their flu shot at any pharmacy.
- i. Members should not be charged an administration fee of $20 at the pharmacy. If they are, refer to John Anderson for assistance.
2. Doctor’s office
a. Flu shot will be covered at 100%
Travel Vaccines
| Preventive Recommendation | CPT or HCPCS | ICD-10 Diagnosis | Final Coverage Recommendation |
|---|---|---|---|
| Cholera | 90625 – Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use | A00.9 – Cholera, unspecified | Excluded |
| Dengue | 90584 – Dengue vaccine, quadrivalent, live, 2 dose schedule, for subcutaneous use; 90587 – Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use | A90 – Dengue Fever (classical dengue); A91 – Dengue Hemorrhagic Fever | Excluded |
| Hepatitis A | 90632 – Hepatitis A vaccine (HepA), adult dosage, for intramuscular use | B15.9 – Hepatitis A without hepatic coma | Covered as preventive vaccine |
| Hepatitis B | 90746 – Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use | B16.9 – Acute hepatitis B without delta-agent and without hepatic coma | Cover as preventive vaccine |
| Inactivated Polio | 90713 – Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use | A80.9 – Acute poliomyelitis, unspecified | Covered as preventive vaccine |
| Japanese B encephalitis | 90738 – Japanese encephalitis virus vaccine, inactivated, for intramuscular use | A83.0 – Japanese encephalitis | Excluded |
| Lyme vaccine | No active CPT code found for Lyme vaccine | A69.20 – Lyme disease, unspecified | Excluded |
| Measles | 90707 – Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use | B05.9 – Measles without complication | Covered as preventive vaccine |
| Meningococcal vaccines | 90620 – Meningococcal recombinant protein and outer membraine vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use; 90621 – Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use; 90733 – Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use | A39.9 – Meningococcal disease NOS | Requires a Preauthorization |
| Oral polio | No active CPT code found for oral polio vaccine (not offered in the US) | A80.9 – Acute poliomyelitis, unspecified | Excluded |
| Rabies (human diploid-cell vaccine) | 90675 – Rabies vaccine, for intramuscular use; 90676 – Rabies vaccine, for intradermal use | A82.9 – Rabies, unspecified | Requires a Preauthorization |
| Tick-borne encephalitis virus vaccine (Ticovac) | 90626 – Tick-borne encephalitis virus vaccine, inactivate; 0.25 mL dosage, for intramuscular use; 90627 – Tick-borne encephalitis virus vaccine, inactivated; 0.5 mL dosage, for intramuscular use | A84.9 – Tick-borne viral encephalitis, unspecified | Excluded |
| Typhoid, attenuated live bacteria | 90690 – Typhoid vaccine, live, oral | A01.00 – Typhoid fever, unspecified | Excluded |
| Typhoid, inactivated bacteria | 90691 – Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use | A01.00 – Typhoid fever, unspecified | Excluded |
| Yellow fever | 90717 – Yellow fever vaccine, live, for subcutaneous use | A95.9 – Yellow fever, unspecified | Requires a Preauthorization |
| Zaire ebolavirus vaccine, live (Ervebo) | 90758 – Zaire ebolavirus, live, for intramuscular use | A98.4 – Ebola virus disease | Excluded |
Our Mission
Our goal is to lower the cost of healthcare and educate our members along the way.
Company Culture
We aim to provide users with the tools they need to succeed in healthcare. We believe those tools are a simple approach to health benefits, a platform to search and shop for the best care at the best price, and a Health Savings Account (HSA). These ingredients create the secret sauce to changing healthcare.
