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 prenatal and postnatal 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 the UCare 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 that are included in the Affordable Care Act (ACA), MN State Statutes, A and B recommendations from the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP) of 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 don't 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 ages 2, 4, 6, 9, 12, 15, 18 and 24 months |
| 3 – 6 years | 1 visit at age 30 months and 1 visit every year for ages 3 – 6 years |
| 7 – 10 years | 1 visit every 1 – 2 years |
| 11 – 18 years | 1 visit every year |
| VACCINE | RECOMMENDATION |
|---|---|
| Chickenpox (varicella) | 2-dose series with first dose between ages 12 – 15 months and second dose between ages 4 – 6 years. For children ages 7 years and older with no history of the vaccination or disease, 2 doses 4 – 12 weeks apart. |
| COVID-19 | For children ages 6 months to 4 years, 2 – 3 doses of updated COVID-19 vaccine and for ages 5 years and older, 1 – 2 doses of updated COVID-19 vaccine based on vaccine type and number of doses previously received. Parents should check with their child's provider for guidance. Children who are moderately or severely immunocompromised may need additional doses of updated COVID-19 vaccine. Note: You pay nothing for COVID-19 shots in or out of network. |
| Diphtheria, tetanus, pertussis (whooping cough) (Tdap) | 5-dose series with 1 dose of DTaP at ages 2, 4 and 6 months, 1 dose between ages 15 – 18 months and 1 dose between ages 4 – 6 years. 1 booster dose between ages 11 – 12 years. |
| Flu (influenza) | 2 doses 4 weeks apart for healthy children between ages 6 months to 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 influenzae type b | 4-dose series with 1 dose at ages 2, 4 and 6 months and once between ages 12 – 15 months |
| Hepatitis A | 2 doses at least 6 months apart between ages 12 – 23 months. For children not previously immunized, 2 doses can be given at least 6 months apart at your doctor's discretion. |
| Hepatitis B | 3-dose series with first dose to all newborns before leaving the hospital, a second dose between ages 1 – 2 months and a third dose between ages 6 – 18 months |
| HPV (human papillomavirus) | Starting at age 11 years for boys and girls. Two doses are given if younger than age 15 years, which are administered 6 – 12 months apart. Three doses over a 24-week period are given for teens and young adults ages 15 – 18 years. Your doctor may give the vaccine as early as age 9 years if your child is at high risk. |
| Measles, mumps, rubella (MMR) | 1 dose between ages 12 – 15 months and a second between ages 4 – 6 years. Can be given to older children if no history of vaccination or the disease. |
| Meningitis (meningococcal) | 1 dose between ages 11 – 12 years, with another dose at age 16 years. If the first dose is given between ages 13 – 15 years, then give the second dose between ages 16 – 18 years. Doctors may give vaccine as early as age 2 years if your child is at high risk. |
| Pneumonia (pneumococcal) | 1 dose at ages 2, 4 and 6 months and again at ages 12 – 15 months. Children over the age of 2 years can get a single dose if not previously immunized. Children with an underlying medical condition can receive an additional dose. |
| Polio | 4-dose series with first dose at age 2 months, second dose at age 4 months, third dose between ages 16 – 18 months and fourth dose between ages 4 – 6 years |
| Rotavirus | 2-dose series at ages 2 and 4 months or 3-dose series at ages 2, 4 and 6 months based on vaccine type |
| RSV | 1 dose between birth to 8 months old. Those between ages 8 – 19 months who are high risk can receive 1 dose prior to their second RSV season. |
| ASSESSMENTS, SCREENINGS AND COUNSELING | RECOMMENDATION |
|---|---|
| Anemia screening | Universal screening at age 12 months. Selective screening at doctor's discretion if positive risk assessment. |
| Anxiety screening | Universal annual screening for adolescents beginning at age 8 years |
| Autism screening | Universal screening at ages 18 and 24 months |
| Behavioral/Social/Emotional screening |
At each well-child visit |
| Blood pressure, head circumference, body mass index, weight for length and length, height and weight | Universal screening through age 21 years for everything except head circumference (which ends at age 2 years), weight for length (which ends at age 18 months) and blood pressure (which begins at age 3 years with selective screening before, if positive risk assessment) |
| Cavity prevention | Doctors should apply fluoride varnish to teeth for children up to age 5 years who don't have a dental provider (not a dental benefit) |
| Critical congenital heart defect | Once at birth |
| Depression and suicide risk screenings | Universal annual screening for adolescents beginning at age 12 years for major depressive disorder (MDD) |
| Developmental screenings and surveillance | Universal screening at ages 9, 18 and 30 months with ongoing surveillance throughout development |
| Dyslipidemia (cholesterol) screening | Universal screening between ages 9 – 11 years and ages 17 – 21 years. Selective screening if positive risk assessment at ages 2, 4, 6, 8 and 12 – 16 years. |
| Hearing screening | Universal screening for all newborns, at ages 4, 5, 6, 8 and 10 years and once between ages 11 – 14 years, 15 – 17 years and 18 – 21 years. Selective screening at ages 4 months to 3 years and again at ages 7 and 9 years. |
| Hepatitis B screening | For adolescents at high risk |
| HIV screening | Universal screening once between ages 15 – 21 years. Selective screening for adolescents at high risk. |
| Lead screening | Universal screening at ages 12 and 24 months for children at high risk. Risk assessment for lead exposure between ages 6 – 12 months, ages 18 – 24 months and between ages 3 – 6 years. |
| Maternal depression screening | For postpartum people, screening performed at ages 1, 2, 4 and 6 months well-child visits |
| Medical history | At each well-child visit |
| Newborn blood screenings | Newborn blood screening, including bilirubin, hemoglobinopathies, hypothyroidism and phenylketonuria (PKU), as identified by current Federal Health Resources and Services Administration (HRSA) and required by state law |
| Obesity screening counseling | At your doctor's discretion starting at age 6 years |
| Oral health risk assessment | Selective risk assessment through age 6 years |
| Psychosocial/behavioral assessment |
Psychosocial/behavioral assessment at your doctor's discretion |
| Routine vision eye exam | For ages 18 years and under, one per year |
| 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 ages 6 months to 21 years who have fair skin to discuss minimizing exposure to ultraviolet radiation to reduce skin cancer risk |
| Tobacco, alcohol or drug use assessments | For ages 11 – 21 years during each visit. Counseling to those at risk. |
| Tuberculosis (TB) testing | At your doctor's discretion for children at high risk |
| Vision screening (Snellen eye chart) | Universal screening at ages 3 – 6 years and ages 8, 10, 12 and 15 years |
| PRESCRIPTION | RECOMMENDATION |
|---|---|
| Human immunodeficiency virus (HIV) prevention medication | A daily course of pre-exposure prophylaxis (PrEP) using effective antiretroviral therapy for those who are at high risk of HIV infection |
| Gonococcal ophthalmia neonatorum preventive medication | Prophylactic ocular topical medication to prevent gonococcal ophthalmia neonatorum (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 ages 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 years 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 |
| COVID-19 | 1 – 2 doses of updated COVID-19 vaccine based on vaccine type and number of doses previously received. People who are moderately or severely immunocompromised may get additional doses of updated COVID-19 vaccine. Note: You pay nothing for COVID-19 shots in or out of network. |
| Flu (influenza) | 1 dose every year. Note: You pay nothing for flu shots in or out of network. |
| Hepatitis A | 2-dose series or 3-dose series based on vaccine type for those at high risk |
| Hepatitis B | 2-, 3- or 4-dose series based on vaccine type for those at high risk |
| HPV (human papillomavirus) | 3 doses over a 24-week period up to age 26 years |
| Measles, mumps, rubella (MMR) | 1 – 2 doses if no history of vaccination or disease |
| Meningitis (meningococcal) | 1 – 2 doses for ages 19 – 24 years if no history of vaccination. Can be given after age 40 years if at high risk. |
| Pneumonia (pneumococcal) | 1 dose for those ages 65 years and older. Those at high risk or with a history of asthma or smoking should have 1 dose between ages 19 – 64 years with a booster 5 years later. |
| RSV | 1 dose for those ages 60 years and older |
| Shingles (herpes zoster) | 2 doses for those ages 50 years 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 year. |
| ASSESSMENTS, SCREENING AND COUNSELING | RECOMMENDATION |
|---|---|
| Abdominal aortic aneurysm screening | Once for men ages 65 – 75 years with a history of smoking |
| Alcohol misuse screening and counseling | At physical exam |
| Anxiety screening | At physical exam |
| 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 years |
| Colon cancer screening |
For those ages 45 – 75 years, one of the following screenings:
We recommend a colonoscopy because it looks at the entire colon. Those with a family history (first-degree relative) of colorectal cancer or adenomatous polyps should begin screening at age 45 years or 10 years before the youngest case in the immediate family with a colonoscopy every 5 years. |
| Depression and suicide risk screening | At physical exam |
| Diabetes screening | Screening for diabetes as part of a cardiovascular risk assessment in adults ages 35 – 70 years |
| Diet counseling | At your doctor's discretion if you're at high risk for heart and diet-related chronic diseases |
| Falls prevention |
For people ages 65 years and older living in a community setting, exercise interventions to prevent falls for those at increased risk |
| Height, weight and body mass index (BMI) | At physical exam |
| Hepatitis B virus (HBV) screening | Adults at high risk |
| Hepatitis C virus (HCV) screening | Screen adults for Hepatitis C virus (HCV) infection, including pregnant people and asymptomatic adults ages 18 – 79 years without known liver disease |
| HIV screening | All adults up to age 65 years. Screen older adults if at high risk. |
| Lung cancer screening | Annual screening with low-dose computed tomography (LDCT) for adults ages 50 – 80 years who have a 20-pack-a-year smoking history and currently smoke or quit smoking within the past 15 years |
| Medical history | At physical exam |
| Obesity screening and counseling | At physical exam |
| Prostate cancer screening | For men ages 40 years or older who are symptomatic or in a high-risk category and for all men ages 50 years and older, a prostate-specific antigen (PSA) blood test and digital rectal exam |
| Sexually transmitted infection (STI) counseling | Behavioral counseling for sexually active adults who are at increased risk |
| Skin cancer counseling | Adolescents and adults up to age 24 years who have fair skin, to discuss minimizing exposure to ultraviolet radiation to reduce skin cancer risk |
| Syphilis screening | For adults who are at increased risk |
| Tobacco-use screening and counseling | At each visit, including cessation counseling and interventions (see tobacco cessation products in the "Drugs" section) |
| Tuberculosis (TB) testing | At your doctor's discretion if you're at high risk |
| Unhealthy drug use | Adults ages 18 years and older are screened with 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. |
| PRESCRIPTION | RECOMMENDATION |
|---|---|
| Human immunodeficiency virus (HIV) prevention medication | A daily course of pre-exposure prophylaxis (PrEP) using effective 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 (e.g., 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 ages 40 – 75 years. |
| Tobacco cessation products | Adult tobacco users can receive prescription products for $0 copay at in-network pharmacies. OTC products available through smoking cessation program. See your Individual & Family Plans formulary for approved medications. |
Women's health
In addition to the preventive services listed in the Adult Health section, women are also eligible for the following preventive services. This applies to cisgender women and all other persons assigned female at birth (including transgender men and nonbinary persons).
| ASSESSMENTS, SCREENINGS AND COUNSELING | RECOMMENDATION |
|---|---|
| BRCA-related cancer risk assessment and genetic counseling/testing | Risk assessments for asymptomatic women with a family history of breast, ovarian, tubal or peritoneal cancer. Women who test positive should receive genetic counseling and, if indicated after counseling, BRCA testing. Covered once per lifetime. |
| Breast cancer chemoprevention counseling | For women ages 35 years and older, at your doctor's discretion for people at high risk of breast cancer who may benefit from chemoprevention |
| Breast cancer screening | For women ages 40 years and older, a screening mammography every 1 – 2 years, which includes 2D and 3D mammography or digital tomosynthesis and some additional diagnostic services or testing following the screening mammography when necessary |
| Cervical cancer screening and human papillomavirus testing | For women ages 21 – 29 years, screening with cervical cytology (Pap) alone every 3 years. For ages 30 – 65 years, screening with cervical cytology (Pap) alone every three years, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, OR every 5 years with hrHPV testing in combination with cytology (cotesting). |
| Chlamydia screening | For ages 24 years or younger, screening for sexually active women. For ages 25 years or older, screening for those who are at increased risk for infection. |
| Diabetes screening after pregnancy | Women 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 and interpersonal violence screening and counseling | Annually |
| Gonorrhea screening | For ages 24 years or younger, screening for sexually active women. For ages 25 years or older, screening for those who are at increased risk for infection. |
| Obesity prevention | Counseling for women ages 40 – 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 | For women who no longer menstruate and are at increased risk of osteoporosis, screening with bone measurement testing to prevent osteoporotic fractures |
| Preventive guidance for breast self-exam and menopause counseling | At doctor's discretion |
| Urinary incontinence | Annually |
| Well-woman visits (physical exams) | 1 visit every 1 – 3 years |
| PRESCRIPTION | RECOMMENDATION |
|---|---|
| Breast cancer prevention medication | Risk-reducing medications for women ages 35 years and older with an increased risk of breast cancer who have never been diagnosed with breast cancer |
| Folic acid supplements | Women of childbearing age: 0.4 – 0.8 mg at your doctor's discretion |
| PRESCRIPTION | RECOMMENDATION | BENEFIT LEVEL |
|---|---|---|
| Barrier |
|
Generic contraceptive 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 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, 1 dose before discharge from health care facility |
| 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 – 26 years | No | Yes, if between ages of 9 – 26 years |
| 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 |
| RSV | No | Yes, between 32 – 36 weeks' gestation | No |
| 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 |
| Healthy weight and weight gain in pregnancy | Behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy |
| Hepatitis B screening | During the first prenatal visit |
| HIV screening | All pregnant people during each pregnancy |
| Perinatal depression counseling | For pregnant and postpartum people, counseling interventions for those who are at increased risk |
| Preeclampsia screening | Blood pressure measurements throughout pregnancy |
| Prenatal ultrasound | One ultrasound per pregnancy |
| Rh(d) 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 |
| Syphilis screening |
3 times during pregnancy
|
| 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 |