2019 Preventive Health Care Guidelines
 

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 UCare Customer Services at the number on the back of your member ID card.

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 free 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.

Any time you have questions about your coverage, call UCare Choices Customer Services at the number on the back of your member ID card.

Examples of preventive and diagnostic services

Services It's preventive (free) 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.
Urinalysis Never preventive. Always diagnostic. National guidelines say there’s no need for this test unless you have symptoms.

 

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.
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.  
Autism screening Universal screening at 18 and 24 months.  
Blood pressure Universal screening beginning at age 3. Selective screening if positive risk assessment (less than 3).  
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 screening Universal for adolescents. Annually beginning at age 12.  
Developmental screening Universal screening at 9, 18 and 30 months with ongoing surveillance throughout development.  
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.  
Height, weight and body mass percentile Height and weight at each visit up to age 2. After age 2, body mass percentile.  
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 mother-child relationship.  
Medical history At each well-child visit.  
Newborn blood screenings including bilirubin screening As identified by the Federal Health Resources and Services Administration. Also governed 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 10–21 who have fair skin to discuss minimizing exposure to ultraviolet radiation to reduce skin cancer risk.  
Tobacco-use screening and counseling During each visit. Includes cessation interventions for tobacco users and expanded counseling for pregnant tobacco users.  
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
Gonorrhea preventive medication Once at birth.
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.
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.
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 dose 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) 1 dose for those 50 and older.
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 50–75, one of the following screenings:
  • Colonoscopy every 10 years, including colonoscopy prep medication
  • CT colonography every 10 years
  • Flexible sigmoidoscopy every 5 years
  • Fecal occult blood test annually
  • Cologuard® (at-home resting option) every 3 years
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 40 or 10 years before the youngest case in the immediate family with a colonoscopy every 5 years.
Depression screening During physical exam.
Diabetes screening Screening for diabetes as part of a cardiovascular risk assessment in adults aged 40 – 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 Adults at high risk and a one-time screening for adults born between 1945 and 1965.
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 55–80 who have a 30– 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 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 For 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 women.
Tuberculosis (TB) testing At your doctor’s discretion if you’re at high risk.

 

Prescription Recommendation
Low-dose aspirin therapy to prevent heart disease For adults 50–59 who are at risk for CVD, are not at increased risk for bleeding, have a life expectancy of at least 10 years and are willing to take low-dose aspirin daily for at least 10 years.
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.

 

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 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. BRCA testing is covered once per lifetime.
Breast cancer counseling At your doctor’s discretion for women at high risk of breast cancer who may benefit from chemoprevention.
Breast cancer screening Screening mammogram covered every 1-2 years for women ages 50–74. Begin at age 40 for those at high risk or at your doctor’s discretion.
Diabetes Mellitus 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 to 6 weeks postpartum. Women with a negative initial postpartum screening test should be rescreened at least every 3 years for a minimum of 10 years after pregancy. For women with a positive postpartum screening test result, testing to confirm the diagnosis of diabetes is indicated regardless of the inital 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.
Osteoporosis screening Women who are postmenopausal.
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 women 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 women 35 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 - 0.8mg at your doctor’s discretion.

 

Prescription Recommendation Benefit level
Barrier
  • Diaphragms
  • Condoms
  • Contraceptive sponge
  • Cervical cap
  • Spermicide
Generic contraceptive methods and the ring methods for women are covered at 100% (free). Your deductible and/or prescription copayment applies for brand-name contraceptives when there is a generic available.
Emergency
  • Ella®
  • Next Choice® One Dose
  • My Way®
Covered at 100%.
Hormonal
  • Oral
  • Injectable
  • Patch
  • Ring
Generic contraceptive methods and the ring methods for women are covered at 100% (free). Your deductible and/or prescription copayment applies for brand-name contraceptives when there is a generic available.
Implantable
  • IUDs
  • Implantable rod
Generic contraceptive methods and the ring methods for women are covered at 100% (free). 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 women

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 No
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 during first trimester.
Breastfeeding support, supplies and counseling Lactation support and counseling to pregnant and postpartum women, including costs for rental of breastfeeding equipment.
Gestational diabetes screening Women 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 women during each pregnancy.
Preeclampsia screening Blood pressure measurements throughout pregnancy.
Rh incompatibility screening On first visit and follow-up testing for women at high risk.
Routine maternity care Routine prenatal and postpartum visits for all pregnant women.
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 women.

 

Prescription Recommendation
Low-dose aspirin therapy Preventive medication after 12 weeks of gestation in women at high risk for preeclampsia.

 


UC FVC_122718 IA (12272018)
January 2019