Preventive care services

Covered services include:

• One baseline mammogram between the ages of 35 and 39
• One screening mammogram every 12 months for women aged 40 and older
• Clinical breast exams once every 24 months

Covered services include:

• For all women: Pap tests and pelvic exams are covered once every calendar year
• If you’re at high risk of cervical or vaginal cancer or you’re of childbearing age and have had an abnormal Pap test within the past three years: one Pap test every calendar year
• If you receive a cervical or vaginal cancer screening or other diagnostic procedure during which the findings require surgical intervention, an office copayment or an outpatient surgical copayment may apply.

The following screening tests are covered:

• Colonoscopy has no minimum or maximum age limitation and is covered once every 120 months (10 years) for patients not at high risk, or 48 months after a previous flexible sigmoidoscopy for patients who aren’t at high risk for colorectal cancer, and once every 24 months for high-risk patients after a previous screening colonoscopy.
• Computed tomography colonography for patients 45 years and older who are not at high risk of colorectal cancer and is covered when at least 59 months have passed following the month in which the last screening computed tomography colonography was performed or 47 months have passed following the month in which the last screening flexible sigmoidoscopy or screening colonoscopy was performed. For patients at high risk for colorectal cancer, payment may be made for a screening computed tomography colonography performed after at least 23 months have passed following the month in which the last screening computed tomography colonography or the last screening colonoscopy was performed.
• Flexible sigmoidoscopy for patients 45 years and older. Once every 120 months for patients not at high risk after the patient received a screening colonoscopy. Once every 48 months for high-risk patients from the last flexible sigmoidoscopy or computed tomography colonography.
• Screening fecal-occult blood tests for patients 45 years and older. Once every 12 months.
• Multitarget stool DNA for patients 45 to 85 years of age and not meeting high risk criteria. Once every year.
• Blood-based Biomarker Tests for patients 45 to 85 years of age and not meeting high risk criteria. Once every three years.
• Colorectal cancer screening tests include a follow-on screening colonoscopy after a Medicare-covered non-invasive stool-based colorectal cancer screening test returns a positive result.
• Colorectal cancer screening tests include a planned screening flexible sigmoidoscopy or screening colonoscopy that involves the removal of tissue or other matter, or other procedure furnished in connection with, as a result of, and in the same clinical encounter as the screening test.

For men aged 50 and older, covered services include the following:

• Digital rectal exam once every calendar year
• Prostate Specific Antigen test once every calendar year

Prior authorization is required from the plan. For qualified people, a low dose computed tomography (LDCT) is covered every 12 months.

Eligible members are people age 50 to 77 who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack-years and who currently smoke or have quit smoking within the last 15 years, who get an order for LDCT during a lung cancer screening counseling and shared decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non-physician practitioner.

For LDCT lung cancer screenings after the initial LDCT screening: the member must get an order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non-physician practitioner. If a physician or qualified non-physician practitioner elects to provide a lung cancer screening counseling and shared decision-making visit for later lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits.

These screenings may be fasting or non-fasting glucose tests, A1C tests, or other glucose tests approved by Medicare as appropriate.

We cover diabetes screenings if you have any of these risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes.

You may be eligible for up to two diabetes screenings every 12 months following the date of your most recent diabetes screening test.

For all people who have diabetes (insulin and non-insulin users). Covered services include:

• Supplies to monitor your blood glucose: blood glucose monitors, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors.
• Diabetes testing supplies¹ (meters and strips) obtained through the pharmacy are limited to Ascensia (Contour) branded products. A medical exception will be required for all other diabetes testing supplies. All test strips are subject to a quantity limit of 204 strips per 30 days.
• Continuous Glucose Monitoring¹ (CGM) products obtained through the pharmacy are subject to prior authorization and quantity limits. Preferred CGM products obtained through the pharmacy are Dexcom and Abbott Freestyle Libre. A medical exception will be required for all other CGM products. All CGM products are subject to a quantity limit of one (1) receiver per 365 days, one (1) transmitter per 90 days, and sensors per product labeling.
• For people with diabetes who have severe diabetic foot disease: one pair per calendar year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting.
• Diabetes self-management training is covered under certain conditions.
• Certain telehealth services, including diabetes self-management training. You have the option of receiving these services either through an in-person visit or via telehealth. If you choose to receive these services via telehealth, then you must use a network provider that currently offers the service via telehealth. You may use a phone, computer, tablet, or other video technology.

Covered for eligible members under all Medicare health plans, the Medicare Diabetes Prevention Program is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.

A one-time screening ultrasound for people at risk. This screening is covered if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist.

We cover one visit every calendar year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating healthy.

Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every five years.

Covered Medicare Part B services include:

• Pneumonia vaccines
• Flu/influenza shots (or vaccines), once each flu/influenza season in the fall and winter, with additional flu/influenza shots (or vaccines) if medically necessary
• Hepatitis B vaccines if you’re at high or intermediate risk of getting Hepatitis B
• COVID-19 vaccines
• Other vaccines if you’re at risk and they meet Medicare Part B coverage rules.

We also cover most other adult vaccines under our Part D drug benefit. Not all of our Medicare Advantage plans include Part D benefits. Please refer to your Evidence of Coverage for details.

Tetanus antitoxin or booster vaccines are covered under the medical benefit only when directly related to the treatment of an injury. In the absence of injury, preventive immunizations (vaccination or inoculation) are not covered under the medical benefit.

We cover one screening for depression every calendar year. The screening must be done in a primary care setting that can provide follow-up treatment and/or referrals.

We cover one alcohol misuse screening every calendar year for adults (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to four brief face-to-face counseling sessions every calendar year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting.

Smoking and tobacco use cessation counseling is covered for outpatient and hospitalized patients who meet these criteria:

• Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
• Are competent and alert during counseling
• A qualified physician or other Medicare-recognized practitioner provides counseling

We cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the patient getting up to eight sessions per year.

For people who ask for an HIV screening test or are at increased risk for HIV infection, we cover one screening exam every 12 months.

If you are pregnant, we cover up to three screening exams during a pregnancy.

If you don’t have HIV, but your doctor or other health care practitioner determines you're at an increased risk for HIV, we cover pre-exposure prophylaxis (PrEP) medication and related services.

If you qualify, covered services include:

• FDA-approved oral or injectable PrEP medication. If you’re getting an injectable drug, we also cover the fee for injecting the drug.
• Up to eight individual counseling sessions (including HIV risk assessment, HIV risk reduction, and medication adherence) every 12 months.
• Up to eight HIV screenings every 12 months.
• A one-time hepatitis B virus screening.

We cover one Hepatitis C screening if your primary care doctor or other qualified health care provider orders one and you meet one of these conditions:

• You’re at high risk because you use or have used illicit injection drugs.
• You had a blood transfusion before 1992.
• You were born between 1945-1965.

If you were born between 1945-1965 and aren’t considered high risk, we pay for a screening once.

If you’re at high risk (for example, you’ve continued to use illicit injection drugs since your previous negative Hepatitis C screening test), we cover yearly screenings.

We cover STI screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider.

We cover these tests once every calendar year or at certain times during pregnancy. We also cover up to two individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs.

We only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office

If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every calendar year.

Note: Your first annual wellness visit can’t take place within 12 months of your Welcome to Medicare preventive visit. However, you don’t need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you’ve had Part B for 12 months.

For qualified people (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary:

• Procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician’s interpretation of the results

Some plans provide programs for conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and diabetes. Our programs include educational resources and self-management tools. If you are receiving services for any of these conditions, you will receive information by mail and may be contacted by a case management staff member.

This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor.

We cover three hours of one-on-one counseling services during the first year you get medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and two hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to get more hours of treatment with a physician’s order. A physician must prescribe these services and renew their order yearly if your treatment is needed into the next calendar year.

If you have a body mass index of 30 or more, we cover intensive counseling to help you lose weight. This counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan.

Talk to your primary care doctor or practitioner to find out more. Screenings are covered once every calendar year.

Covered services include:

• Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts.
• For people who are at high risk for glaucoma, we cover one glaucoma screening each year. People at high risk of glaucoma include people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older.
• For people with diabetes, screening for diabetic retinopathy is covered once per year.
• Routine eye exams: one exam each calendar year²
• Contact lens fitting/evaluation exam: one exam each calendar year²

Our plan covers the one-time Welcome to Medicare preventive visit. The visit includes a review of your health, as well as education and counseling about preventive services you need (including certain screenings and shots or vaccines), and referrals for other care if needed.

Important: We cover the Welcome to Medicare preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor’s office know you want to schedule your Welcome to Medicare preventive visit.