2023 Preventive Health Care Guidelines for Individual & Family Plan members
Be informed
We want to help you understand and take advantage of your preventive coverage for things like routine exams, flu shots and well-child visits: helping you stay well and healthy is at the center of everything we do.
This guide will help you understand the differences between preventive and diagnostic care to help you make informed health care decisions and avoid unexpected costs.
If you have questions about covered services or any potential costs to you, call the customer service number on the back of your member ID card or send a secure message through your online member account.
What is preventive care?
Preventive care lets your doctor find potential health problems before you feel sick, when many issues are easier to treat. This is why it’s important to visit your doctor regularly to stay healthy. Some services provided as preventive include:
- Immunizations for adults and children
- Annual physical exams
- Routine pre-natal and post-natal visits
- Certain lab tests
- Screenings for certain types of cancer
The preventive services listed in these guidelines are at no additional cost when you see an in-network provider. To find health care providers who are part of UCare’s network, search the network.
These guidelines may change throughout the coverage year based on new research and recommendations.
Be informed:
In-network and non-network care
Getting care from in-network providers and facilities is one way to help manage your health care costs. It’s important to understand that your in-network provider may sometimes provide care at non-network clinics or hospitals. Whenever possible, ask about the network status of providers, facilities and support staff before office visits or procedures.
The preventive services UCare offers are based on guidelines from the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Bright Futures/American Academy of Pediatrics Periodicity Schedule.
What is diagnostic care?
A service or test is diagnostic when it monitors, diagnoses or treats an existing health problem. If you have a chronic disease such as diabetes, your doctor may monitor your condition with tests. Or you may go to your doctor with a symptom such as a stomachache. In each of these cases, any tests or services would be diagnostic because they are used to treat an existing condition or as a follow-up to symptoms you have.
How do I know if a service is preventive or diagnostic?
The key difference between a preventive and diagnostic test is whether it is done before you have any symptoms.
The same service from your doctor could be preventive or diagnostic, depending on the circumstances. If the service or test is diagnostic, you will be responsible for any out-of-pocket costs that apply. In general:
- If you have an existing condition, your doctor will monitor your condition with tests. Because these tests manage your condition, they’re diagnostic.
- If you have a preventive screening and a health condition shows up, your doctor may order follow-up tests. In this case, the tests are diagnostic.
- If your doctor orders tests based on symptoms you’re having, these tests are diagnostic.
Preventive vs diagnostic
Understand your coverage
It’s important to remember that preventive and diagnostic care can happen during the same doctor visit. For example, let’s imagine your doctor checks your blood sugar level. If you do not have diabetes, this test would be considered preventive. However, if you have previously been diagnosed with diabetes, it would be diagnostic since the test is monitoring an existing condition. You would be responsible for out-of-pocket costs in this instance.
The more you know about your health coverage, including the difference between preventive and diagnostic care, the better your health care decisions will be and the fewer surprises you’ll have when statements or bills arrive.
Examples of preventive and diagnostic services
| Services | It's preventive (at no additional cost) when... | It's diagnostic when... |
|---|---|---|
| Colon cancer screening | Your doctor wants to screen for signs of colon cancer based on your age or family history. If a polyp is found and removed during the screening, the colonoscopy, polyp removal and testing are preventive. | You’re having a health problem, such as bleeding or irregularity. |
| Complete blood count (CBC) | Never preventive. | Always diagnostic. Studies show there’s no need for this test unless you have symptoms. |
| Diabetes screening | A blood glucose test is used to detect problems with your blood sugar, even though you don’t have symptoms. | You’ve been diagnosed with diabetes and your doctor checks your A1c. |
| Metabolic panels | Never preventive. | Always diagnostic. Studies show that a metabolic test isn’t useful for detecting or preventing illnesses. |
| Osteoporosis screening | Your doctor recommends a bone density test based on your age or family history. | You’ve had a health problem or your doctor wants to determine the success of a treatment. |
| Thyroid tests | Done as part of newborn screening within the first 90 days from birth as required by state mandate. | An adult has symptoms, according to national guidelines. |
| Urinalysis | A urine culture is used to screen pregnant people at 12-16 weeks’ gestation or at the first prenatal visit, if later, for bacteria in the urine, according to United States Preventive Services Task Force (USPSTF) recommendations. | Symptoms are present, according to national guidelines. |
Children’s health
| Ages | Recommendation |
|---|---|
| Newborn | 1 visit 3–5 days after discharge. |
| 0-2 years | 1 visit at 2, 4, 6, 9, 12, 15, 18 and 24 months. |
| 3-6 years | 1 visit at 30 months and 1 visit every year for ages 3–6. |
| 7-10 years | 1 visit every 1–2 years. |
| 11-18 years | 1 visit every year. |
| Vaccine | Recommendation |
|---|---|
| Chickenpox (varicella) | 1 dose between 12–15 months. Second dose between 4–6 years. For kids 13 and older with no history of the vaccination or disease, 2 doses 4–8 weeks apart. |
| Diphtheria, tetanus, whooping cough (pertussis) | 5 total doses with 1 dose of DTaP at 2, 4 and 6 months, 1 dose between 15–18 months and 1 dose between 4–6 years. |
| Flu (influenza) | 2 doses 4 weeks apart for healthy children between 6 months and 8 years the first time they get the vaccine. Children who’ve previously had the flu shot can receive 1 dose annually. Note: You pay nothing for flu shots in or out of network. |
| Haemophilus influenza type b | 1 dose at 2, 4 and 6 months and once between 12–15 months. |
| Hepatitis A | 2 doses at least 6 months apart between 12–23 months. For children not previously immunized, 2 doses can be given at least 6–18 months apart at your doctor’s discretion. |
| Hepatitis B | 1 dose to all newborns before leaving the hospital; a second dose between 1–2 months and a third dose between 6–18 months. May begin between 2–18 years if not immunized as a baby. |
| HPV (human papillomavirus) | Starting at age 11 for boys and girls. Two doses are given if younger than age 15, which are administered 6–12 months apart. Three doses are given for teens and young adults ages 15–18. Your doctor may give the vaccine as early as age 9 if your child is at high risk. |
| Polio | 1 dose at 2 and 4 months and between 16–18 months (3 doses total). Then, 1 dose between 4–6 years. |
| Measles, mumps, rubella (MMR) | 1 dose between 12–15 months and a second between 4–6 years. Can be given to older children if no history of vaccination or the disease. |
| Meningitis (meningococcal) | 1 dose between 11–12 years, with another dose at 16 years. If the first dose is given between 13–15 years, then give the second dose between 16–18 years. Doctors may give vaccine as early as age 2 if your child is at high risk. |
| Pneumonia (pneumococcal) | 1 dose at 2, 4 and 6 months and again at 12–15 months. Children over age 2 can get a single dose if not previously immunized. Children with an underlying medical condition can receive an additional dose. Children at high risk can be vaccinated after age 7. |
| Rotavirus | 1 dose at 2, 4 and 6 months. |
| Assessments, screenings and counseling | Recommendation | |
|---|---|---|
| Alcohol and drug use risk assessment | Ages 11–18 during each visit. Counseling to those at risk. | |
| Anemia screening | Universal screening at 12 months. Selective screening at doctor’s discretion if positive risk assessment. | |
| Anxiety screening | Universal for adolescents. Annually beginning at age 8. | |
| Autism screening | Universal screening at 18 and 24 months. | |
| Cavity prevention | Doctors should apply fluoride varnish to teeth for children up to age 5 who do not have a dental home. (Not a dental benefit.) | |
| Critical congenital heart defect | Once at birth. | |
| Depression, major depressive disorder (MDD) screenings | Universal for adolescents. Annually beginning at age 12. | |
| Developmental screenings and assessments | Universal screening at 9, 18 and 30 months with ongoing surveillance throughout development. Psychosocial/behavioral assessment at your doctor’s discretion. | |
| Dyslipidemia (Cholesterol) screening | Universal screening between ages 9–11 and 17–21. Selective screening if positive risk assessment at ages 2, 4, 6, 8 and 12–16. | |
| Hearing loss screening | Universal screening for all newborns and at ages 4, 5, 6, 8, 10 and once between ages 11–14, 15–17 and 18–21. Selective screening at 4 months–3 years and again at ages 7 and 9 years. | |
| Blood pressure, height, weight, length and body mass percentile index | Universal screening through age 21 for everything except head circumference, which ends at age 2, and blood pressure which begins at age 3 with selective screening before, if positive risk assessment. | |
| Hepatitis B screening | Adolescents at high risk. | |
| HIV screening | Universal screening once between age 15–18 years. Selective screening for adolescents at high risk. | |
| Lead screening | Universal screening at 12 and 24 months for children at high risk. Risk assessment for lead exposure between 6–12 months, 18–24 months and between 3–6 years. | |
| Maternal depression screening | Screening for maternal and perinatal and post-partum depression to support the parent-child relationship. | |
| Medical history | At each well-child visit. | |
| Newborn blood screenings | Newborn blood screening, including bilirubin, hemoglobinopathies, hypothyroidism, phenylketonuria (PKU) and anemia, as identified by current Federal Health Resources and Services Administration (HRSA) and required by state law. | |
| Obesity screening and physical activity and nutrition counseling | At your doctor’s discretion starting at age 6. | |
| Oral health risk assessment | Selective risk assessment through 6 years old. | |
| Sexually transmitted infection (STI) prevention, screening and counseling | At your doctor’s discretion for all sexually active adolescents. | |
| Skin cancer counseling | For children and adolescents age 6 months–21 years who have fair skin to discuss minimizing exposure to ultraviolet radiation to reduce skin cancer risk. | |
| Tobacco-use screening and counseling | For school-aged children and adolescents younger than 18 years old. | |
| Tuberculosis (TB) testing | At your doctor’s discretion for children at high risk. | |
| Vision screening | Universal screening at 3–6 years and 8, 10, 12 and 15 years. |
| Prescription | Recommendation |
|---|---|
| Anti-retroviral to prevent HIV infection | A daily course of pre-exposure antiretroviral therapy for those who are at high risk of HIV infection. |
| Gonorrhea preventive medication | Medication administered immediately following birth to prevent eye infection in newborns. |
| Iron supplements | Children ages 6–12 months at risk for iron deficiency. |
| Oral fluoride supplements | Children 6 months to 6 years without fluoride in their water source. |
Adult health
| Ages | Recommendation |
|---|---|
| 19-21 years | Once every 2–3 years; annually if desired. |
| 22–64 years | Once every 1–3 years; annually if desired. |
| 65 and older | Once every year. |
Doses, ages and recommendations vary
| Vaccine | Recommendation |
|---|---|
| Chickenpox (varicella) | 2 doses 4–8 weeks apart for those with no history of the vaccination or disease. |
| Flu (influenza) | 1 dose every year. Note: You pay nothing for flu shots in or out of network. |
| Hepatitis A | 2 doses for those at high risk. |
| Hepatitis B | 3 doses for those at high risk. |
| HPV (human papillomavirus) | 3 doses over a 24-week period up to age 26. |
| Measles, mumps, rubella (MMR) | 1–2 doses if no history of vaccination or disease. Can be given after age 40 if at high risk. |
| Meningitis (meningococcal) | 1–2 doses for ages 19–24 if no history of vaccination. Can be given after age 40 if at high risk. |
| Pneumonia (pneumococcal) | 1 dose for those 65 and older. Those at high risk or with a history of asthma or smoking should have 1 dose between ages 19–64 with a booster 5 years later. |
| Shingles (herpes zoster) | 2 doses for those 50 and over. |
| Tetanus, diphtheria and whooping cough (pertussis) | 1 dose if no history of pertussis vaccine regardless of interval since last tetanus vaccine, followed by tetanus every 10 years. This vaccine is recommended especially if you have contact with children under age 1. |
| Assessments, screening and counseling | Recommendation |
|---|---|
| Abdominal aortic aneurysm screening | Once for men ages 65–75 with a history of smoking. |
| Alcohol misuse screening and counseling | At physical exam. |
| Preventive guidance for family and intimate partner violence, breast self-exam, menopause counseling, safety, falls and injury prevention | At doctor’s discretion. |
| Blood pressure screening | At physical exam. |
| Cardiovascular disease counseling (CVD) | Healthy diet and physical activity counseling to prevent cardiovascular disease among adults with risk factors for CVD |
| Cholesterol test | A fasting test (total cholesterol, LDL, HDL and triglyceride) once every 5 years for adults ages 40–75. |
| Colon cancer screening | For those ages 45–75, one of the following screenings:
|
| Depression screening | During physical exam. |
| Diabetes screening | Screening for diabetes as part of a cardiovascular risk assessment in adults aged 35–70. |
| Diet counseling | At your doctor’s discretion if you’re at high risk for heart and diet-related chronic diseases. |
| Height, weight and body mass index (BMI) | During physical exam. |
| Hepatitis B screening | Adults at high risk. |
| Hepatitis C screening | Screen adults for Hepatitis C virus (HCV) infection, including pregnant people and asymptomatic adults 18-79 years old without known liver disease. |
| HIV screening | All adults up to age 65. Screen older adults if at high risk. |
| Lung cancer screening | Annual screening (including CT) for adults ages 50–80 who have a 20-pack a year smoking history and currently smoke or quit smoking within the past 15 years. |
| Medical history | During physical exam. |
| Obesity screening and counseling | All adults during physical exam. |
| Prostate cancer screening | Men 40 years of age or older who are symptomatic or in a high-risk category and for all men 50 years of age and older. A prostate-specific antigen blood test and digital rectal exam. |
| Sexually transmitted infection (STI) counseling and screening | Annual screening and counseling for chlamydia, gonorrhea and syphilis for adults who are at increased risk. |
| Skin cancer counseling | Adolescents and adults up to age 24 who have fair skin, to discuss minimizing exposure to ultraviolet radiation to reduce skin cancer risk. |
| Tobacco-use screening and counseling | At each visit, including cessation counseling and interventions (see tobacco cessation products in the “Drugs” section). Expanded counseling for pregnant people. |
| Tuberculosis (TB) testing | At your doctor’s discretion if you’re at high risk. |
| Prescription | Recommendation |
|---|---|
| Antiretroviral to prevent HIV infection | A daily course of pre-exposure antiretroviral therapy for those who are HIV negative but at high risk of infection. |
| Low-to-moderate dose statin to prevent cardiovascular/heart disease | Adults ages 40–75 years who have one or more risk factors (i.e., dyslipidemia, diabetes, hypertension or smoking) and have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in those aged 40–75. |
| Tobacco cessation products | Adult tobacco users can receive prescription products for $0 copay in pharmacy. OTC products available through smoking cessation program. See your Individual & Family Plans formulary for approved medications. |
| Unhealthy drug use | Screen adults 18 years and older by asking questions about unhealthy drug use when services for accurate diagnosis, effective treatment and appropriate care can be offered or referred. Screening does not include testing biological specimens. |
Women’s health
In addition to the preventive services listed in the Adult Health section, women are also eligible for the following preventive services:
| Assessments, screenings and counseling | Recommendation |
|---|---|
| BRCA risk assessment and genetic counseling/testing | Risk assessments for asymptomatic people with a family history of breast, ovarian, tubal or peritoneal cancer. People who test positive should receive genetic counseling and, if indicated after counseling, BRCA testing. BRCA testing is covered once per lifetime. |
| Breast cancer counseling | At your doctor’s discretion for people at high risk of breast cancer who may benefit from chemoprevention. |
| Breast cancer screening | Breast cancer screening, which includes 2D and 3D mammography or digital breast tomosynthesis, every 1-2 years for people age 40 and older. |
| Diabetes Mellitus after pregnancy | People with a history of gestational diabetes mellitus (GDM) who are not pregnant and who have not already been diagnosed with type 2 diabetes should be screened. The first test ideally takes place within the first year after pregnancy and can be conducted as early as 4—6 weeks postpartum. People with a negative initial postpartum screening test should be rescreened at least every 3 years for a minimum of 10 years after pregnancy. For people with a positive postpartum screening test result, testing to confirm the diagnosis of diabetes is indicated regardless of the initial test. |
| Domestic violence and intimate partner violence screening and counseling | Annually. |
| HIV counseling and screening | Adults up to age 65. Screen older adults if at high risk. |
| Obesity Prevention | Counseling for ages 40 to 60 years with normal or overweight body mass index (BMI) (18.5-29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity. |
| Osteoporosis screening | People who no longer menstruate. |
| Pap and HPV test (cervical cancer screening) | Ages 21—29: screen for cervical cancer every 3 years with cytology alone; Ages 30—65: screen for cervical cancer every 3 years with cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). |
| Sexually transmitted infection (STI) prevention counseling and screening | Annual screening and counseling for chlamydia, gonorrhea and syphilis for people who are at high risk. |
| Urinary incontinence | Annually. |
| Well-woman visits (physical exams) | 1 visit every 1–3 years. |
| Prescription | Recommendation |
|---|---|
| Breast cancer prevention medication | Risk-reducing medications for people 35 and older with an increased risk of breast cancer who have never been diagnosed with breast cancer. |
| Folic acid supplements | People of childbearing age: 0.4 - 0.8mg at your doctor’s discretion. |
| Prescription | Recommendation | Benefit level |
|---|---|---|
| Barrier |
|
Generic contraceptive methods and the ring methods are covered at 100% (at no additional cost). Your deductible and/or prescription copayment applies for brand-name contraceptives when there is a generic available. |
| Emergency |
|
Covered at 100%. Search our drug list for specific covered contraceptives |
| Hormonal |
|
Generic contraceptive methods and the ring methods are covered at 100% (at no additional cost). Your deductible and/or prescription copayment applies for brand-name contraceptives when there is a generic available. |
| Implantable |
|
Generic contraceptive methods and the ring methods are covered at 100% (at no additional cost). Your deductible and/or prescription copayment applies for brand-name contraceptives when there is a generic available. |
| Permanent | Tubal ligation | Covered at 100% for outpatient facilities. If received during an inpatient stay, only the services related to the tubal ligation are covered in full. |
Pregnant people
If you’re currently pregnant, are thinking about becoming pregnant or have recently had a baby, these preventive care recommendations are covered in addition to the services listed in the Adult Health and Women’s Health sections. Be aware that your doctor may offer additional tests, screenings or services (for example, high-risk prenatal services). These additional services are not part of the preventive services covered by health plans and you may be responsible for out-of-pocket costs.
| Vaccine | Before pregnancy | During pregnancy | After pregnancy |
|---|---|---|---|
| Chickenpox (varicella) | Yes, avoid getting pregnant for 4 weeks | No | Yes, immediately post-partum |
| Hepatitis A | Yes, if at risk | Yes, if at risk | Yes, if at risk |
| Hepatitis B | Yes, if at risk | Yes, if at risk | Yes, if at risk |
| HPV (human papillomavirus) | Yes, if between ages of 9 and 26 | No | Yes, if between ages of 9 and 26 |
| Flu shot | Yes | Yes | Yes |
| Measles, mumps, rubella (MMR) | Yes, avoid getting pregnant for 4 weeks | No | Yes, 1 dose before discharge from health care facility |
| Meningitis (meningococcal) | If indicated | If indicated | If indicated |
| Pneumonia (pneumococcal) | If indicated | If indicated | If indicated |
| Tetanus | Yes (Tdap preferred) | If indicated | Yes (Tdap preferred) |
| Tetanus, diphtheria, whooping cough (1 dose only) | Yes | Yes | Yes |
| Assessments, screenings and counseling | Recommendation |
|---|---|
| Bacteriuria screening with urine culture | Between 12—16 weeks gestation or at the first prenatal visit, if later. |
| Breastfeeding support, supplies and counseling | Lactation support and counseling to pregnant and postpartum people, including costs for rental or purchase of breastfeeding equipment. |
| Gestational diabetes screening | People 24–28 weeks pregnant and those identified as high risk for gestational diabetes. |
| Hepatitis B screening | During the first prenatal visit. |
| HIV screening | All pregnant people during each pregnancy. |
| Preeclampsia screening | Blood pressure measurements throughout pregnancy. |
| Rh incompatibility screening | On first visit and follow-up testing for people at high risk. |
| Routine maternity care | Routine prenatal and postpartum visits for all pregnant people. |
| Routine prenatal ultrasound | One standard ultrasound per pregnancy. |
| Sexually transmitted infection (STI) screening | Screening and counseling for chlamydia, gonorrhea and syphilis. |
| Tobacco-use screening and counseling | Expanded counseling for pregnant people. |
| Prescription | Recommendation |
|---|---|
| Low-dose aspirin therapy to prevent preeclampsia | Preventive medication after 12 weeks of gestation in people at high risk for preeclampsia. |