Preventive care for men
List of what's covered
Cancer screenings and counseling
Who should get it: Age 45 to 75*
Description: Screening for colon / colorectal cancer in adults age 45 to 75. *Effective no later than April 1, 2022, colorectal cancer screening and associated services are covered at 100% for eligible members aged 45 and older
Frequency: Using fecal blood testing (gFOBT or FIT) annually, Cologuard every 3 years, sigmoidoscopy or CT / virtual colonography every 5 years, or colonoscopy every 10 years. These tests are available in network
More information:
- If you have a positive fecal blood test (gFOBT or FIT or Cologuard), or visualization test (CT colonography or sigmoidoscopy), your doctor may order a follow up colonoscopy. This follow up colonoscopy will be covered at 100%
- If you had a polyps removed during a previous preventive screening colonoscopy, future colonoscopies will be covered but may not be considered preventive so you may have out of pocket costs
- Your doctor may order a colonoscopy more frequently than every 10 years. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs
- Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%
- Provider consultation prior to the colonoscopy procedure is covered at 100%
- Certain bowel preparation medications for a screening colonoscopy are covered at 100% when prescribed by a doctor You can find these medications in the ACA preventive drug list
- If there is a medical reason you cannot use a generic bowel preparation medication, your doctor should review this ACA Copay Waiver Criteria (PDF); if you meet these criteria, they can submit this information on the ACA Copay Waiver form (PDF)
- Barium enema is a covered service but not at 100% so you may have out of pocket costs
Who should get it: Age 50 to 80 and high risk due to smoking or other exposure
Description: Annual screening for lung cancer with low-dose Computed Tomography scan in adults ages 50 to 80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years
Frequency: Annually if you qualify as high risk
More information: Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
Who should get it: Age 10 to 24 with fair skin
Description: Counseling young adults, adolescents, children, and parents of young children about minimizing exposure to UV radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer
Frequency: May vary based on your health so ask your doctor
Disease prevention and heart health
Who should get it: Men age 65 to 75 if you have ever smoked
Description: Screening by ultrasonography
Frequency: Once
Who should get it: Adults aged 35 to 70 who are overweight or obese
Description: Screening for prediabetes and type 2 diabetes for adults aged 35 to 70 who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions
Frequency: May vary based on your health so ask your doctor
Who should get it: Age 18 or older
Description: Screening for high blood pressure, or hypertension, in adults with office blood pressure measurement. Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment
Frequency: May vary based on your health so ask your doctor
More information: Blood pressure monitors will be covered at 100% for members who have an elevated blood pressure during their doctor's visit, but have not been diagnosed with high blood pressure. This will cover ambulatory blood pressure monitors and home blood pressure monitors. Home blood pressure monitors must be purchased from an in-network DME provider. To find a DME provider, use our Find Care tool
Who should get it: Age 18 or older if at increased risk
Description: Screening for latent tuberculosis in populations at increased risk
Frequency: May vary based on your health so talk to your doctor
Who should get it: Adults aged 40 to 75 with certain risk factors
Description: Statins for the primary prevention of CVD in adults aged 40 to 75 years who have 1 or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD event risk of 10% or greater. Screening for high cholesterol is also covered
More information:
- Medications covered at 100%: Lovastatin (20 or 40 mg) or Pravastatin (10, 20, 40 or 80 mg). If there is a medical reason you cannot use a generic statin, your doctor should review this ACA Copay Waiver Criteria (PDF); if you meet these criteria, they can submit this information on the ACA Copay Waiver form (PDF)
- Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD
Sexual health
Who should get it: Men at high risk of infection
Description: Screening for Hepatitis B for those at high risk of infection
Frequency: May vary based on your health so ask your doctor
Who should get it: Men aged 18 to 79
Description: Screening for Hepatitis C in adults aged 18 to 79
Frequency: May vary based on your health so ask your doctor
Who should get it: Persons at high risk of acquiring HIV
Description: Prescribe pre-exposure prophylaxis (PrEP) using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV
More information: Medications covered at 100%: emtricitabine / tenofovir (generic Truvada®) Descovy®, Apretude®, and Yeztugo®
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If either of these two scenarios apply to you, have your provider fill out and fax the ACA Copay Wavier form (PDF)
- Scenario 1: Brand Truvada® may be made available if you are clinically unable to use generic Truvada®
- Scenario 2: Your claim for emtricitabine / tenofovir (generic Truvada®), Descovy®, Apretude®, or Yeztugo® is not paying at 100% and you are using it for PrEP
Frequency: May vary based on your health so ask your doctor
Who should get it: Men to age 65 or older if at increased risk
Description: Screening for Human Immunodeficiency Virus (HIV). Older men who are at increased risk should also be screened
Frequency: May vary based on your health so ask your doctor
Who should get it: Sexually active men at increased risk
Description: Behavioral counseling for sexually active adults at increased risk for sexually transmitted infections (STIs)
Frequency: May vary based on your health so ask your doctor
Who should get it: Men at high risk of infection
Description: Screening for syphilis in those at increased risk of infection
Frequency: May vary based on your health so ask your doctor
Mental health and substance use disorder
Who should get it: Age 19 to 64
Description: Screening for anxiety disorder in adults
Frequency: May vary on your health so ask your doctor
Who should get it: Age 19 or older
Description: Screening for depression in the adult population
Frequency: Part of any problem or preventive office visit
Who should get it: Age 18 or older
Description: Ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco
Frequency: May vary based on your health so ask your doctor
More information:
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Telephonic counseling available by calling QuitlineNC at 844-8NCQUIT (844-862-7848).
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FDA-approved tobacco cessation prescription medications and OTC nicotine replacement therapy (NRT) covered at 100%
- NRT through QuitlineNC is available without a prescription. Members must enroll in the multi-call program to qualify for up to 12 weeks of NRT. Limited to a 90 day supply each for two cessation efforts
- NRT through the pharmacy benefit is available only with a prescription
- No prescription medication or NRT limit when received via pharmacy benefit
Who should get it: Age 18 or older
Description: Screening adults for unhealthy alcohol use and provides persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use
Frequency: May vary based on your health so ask your doctor
Who should get it: Age 18 or older
Description: Ask questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens)
Frequency: May vary based on your health so ask your doctor
Nutrition and wellness
Who should get it: Age 65 or older
Description: Exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls
Frequency: May vary based on your health so ask your doctor
Who should get it: Adults with cardiovascular risk factors
Description: Offer or refer adults with cardiovascular disease (CVD) risk factors to behavioral counseling interventions to promote a healthy diet and physical activity
Frequency: May vary based on your health so ask your doctor
More information: Preventive care includes 4 treatments provided by a physician and 30 nutritional counseling visits by a licensed dietitian or nutritionist
Who should get it: Age 18 or older
Description: If your body mass index (BMI) is 30 or higher, your doctor should refer you to or offer you intensive, multi-component behavioral interventions
Frequency: May vary based on your health so ask your doctor
More information: Preventive care includes 4 treatments provided by a physician and 30 nutritional counseling visits by a licensed dietician or nutritionist
Immunizations
The following are the recommended vaccines for men that are covered with no out of pocket cost. Doses, recommended ages and recommended populations vary.
See your doctor and refer to the CDC’s posted schedule of immunizations for more information.
- COVID-19
- Haemophilus influenza type b
- Herpes Zoster (Shingles)
- Hepatitis A
- Hepatitis B
- Human papillomavirus (HPV)
- Influenza (Flu)
- Measles, mumps, rubella (MMR)
- Meningococcal
- Mpox
- Pneumococcal
- RSV (Respiratory Syncytial Virus)
- Tetanus-Diphtheria/Tetanus-Diphtheria Acellular Pertussis (Tdap)
- Varicella (Chicken Pox)
Medications
For drug and dosage details, refer to the Affordable Care Act (ACA) Preventive Drug List:
The Affordable Care Act (ACA) has identified certain services as preventive care to be paid at 100%.
- These benefits are available for members of non-grandfathered individual health insurance plans.
- If you get benefits from your employer, you may also have these benefits. If your Summary of Benefits section of your Benefit Booklet contains PREVENTIVE CARE covered under federal law, then you have these benefits at no charge IN-NETWORK.
- These benefits are currently in effect unless otherwise noted.
- Check your Benefit Booklet for details on other preventive care benefits.
- This information is a reference tool and does not guarantee payment of any claims.
- For transgendered individuals, you have access to medically appropriate preventive services.
Remember, to be covered with no out-of-pocket costs, the service must be:
- Provided by an in-network doctor or facility (urgent care facility, outpatient clinic or ambulatory surgery center)
- Filed by your doctor as a preventive care visit
- Identified as preventive care under the Affordable Care Act (ACA)