Preventive care for children

Who should get it: Infants to age 12 months

• Description: Routine iron supplementation for infants; all infants at age 12 months should be screened for anemia
• Frequency: May vary based on your child’s health so ask your doctor
• Exclusions: Over-the-counter (OTC) iron supplements are only covered with a prescription

Who should get it: Newborns

• Description: Assessment of bilirubin level
• Frequency: Once
• More information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

Who should get it: Infants over 6 months

• Description: Part of a wellness office visit for children age 6 months to 16 years
  • Primary care clinicians to prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
  • Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption
• Frequency: May vary based on your child’s health so ask your doctor
• Exclusions: Fluoride varnish services will not be covered beyond the 5th birthday

Who should get it: Newborns

• Description: Screening for congenital hypothyroidism
• Frequency: Once
• More information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

Who should get it: Newborns

• Description: Screening for critical congenital heart defects in newborns
• Frequency: Once

Who should get it: Newborns

• Description: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth
• Frequency: Once

The following are the recommended vaccines for infants 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.

• COVID-19
• Dengue Fever
• Diphtheria, Tetanus-Acellular, Pertussis (DTap)
• Haemophilus Infuenzae Type B (Hib)
• Hepatitis A
• Hepatitis B
• Inactivated Poliovirus (IPV)
• Influenza (Flu)
• Measles, Mumps, Rubella (MMR)
• Pneumococcal
• Rotavirus
• RSV (Respiratory Syncytial Virus)
• Varicella (Chicken Pox)

Who should get it: Newborns

• Description: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth
• Frequency: Once

Who should get it: High-risk newborns

• Description: Prophylactic (preventive) ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum (gonorrhea)
• Frequency: Once
• More information: This medication is generally given to a newborn at the birth facility

Who should get it: Newborns

• Description: Screening for sickle cell disease (Hemoglobinopathies) in newborns
• Frequency: Once
• More information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

Who should get it: From age 11

• Description: Assessment of alcohol and drug use in children, adolescents and teens
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Under age 18

• Description: Directed information from your child’s provider to the parent and / or child regarding developmentally appropriate topics that may not be currently present but might be anticipated. The goals are to inform a family about common situations that may be encountered at each stage of development, prevent unnecessary injuries and allay common misunderstandings. This may include issues such as obesity, tobacco use, safety equipment (e.g., bicycle helmets), and media exposure (e.g., appropriate choices about internet and TV use, movies, music, etc.)
• Frequency: May vary based on your child’s health so ask your doctor.

Who should get it: Children from age 8

• Description: Screening for anxiety in children
• Frequency: May vary based on your health, so ask your doctor

Who should get it: 18 and 24 months

• Description: Screening for autism in children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Age 10 to 24 with fair skin

• Description: Counseling children, adolescents and young adults age 10 to 24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer
• Frequency: May vary based on your child’s health so ask your doctor; considered part of wellness office visit

Who should get it: Children under 16

• Description: Part of a wellness office visit for children age 6 months to 16 years
  • Primary care clinicians to prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
  • Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption
• Frequency: May vary based on your child’s health so ask your doctor
• Exclusions: Fluoride varnish services will not be covered beyond the 5th birthday

Who should get it: Under age 18

• Description: Cholesterol screening in children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: 9, 18, and 30 months

• Description: Screening to assess developmental progress in children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Under age 18

• Description: Monitoring developmental health in children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Under 18

• Description: Screening for hearing health in children
• Frequency: May vary based on your child’s health so ask your doctor

The following are the recommended vaccines for children 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.

• COVID-19
• Dengue Fever
• Diphtheria, Tetanus-Acellular, Pertussis (DTap)
• Haemophilus Infuenzae Type B (Hib)
• Hepatitis A
• Hepatitis B
• Inactivated Poliovirus (IPV)
• Influenza (Flu)
• Measles, Mumps, Rubella (MMR)
• Pneumococcal
• Rotavirus
• RSV (Respiratory Syncytial Virus)
• Varicella (Chicken Pox)

Who should get it: Children up to age 7

• Description: Screening for lead presence in young children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Children age 6 or older

• Description: Screening for obesity; doctor should offer / refer to comprehensive, intensive behavioral interventions to promote improvement in weight status
• Frequency: May vary based on your child’s health so ask your doctor
• More information: Includes 30 nutritional counseling visits

Who should get it: Under age 18

• Description: Screening of child’s mouth to identify oral issues such as tooth decay or delayed teeth
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Under age 18

• Description: Assessment of child’s psychosocial and behavioral development
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: School-aged children or adolescents

• Description: Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents
• Frequency: May vary based on your child’s health so ask your doctor
• Exclusions: Applicable only for members over age 5

Who should get it: Under age 18

• Description: Skin test to detect tuberculosis (TB) in children
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Under age 18

• Description: Vision screening at least once in all children aged 3 to 5 years to detect amblyopia (also known as 'lazy eye') or its risk factors
• Frequency: For over age 5, talk to you doctor about how often your child needs a vision screening

Who should get it: Adolescents up to age 18

• Description: Screening for anxiety in adolescents
• Frequency: May vary based on your health so ask your doctor

Who should get it: Pregnant adolescents

• Description: Clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy
• Frequency: May vary based on your health so ask your child’s doctor

Who should get it: Age 10 to 24 with fair skin

• Description: Counseling children, adolescents and young adults ages 10 to 24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer
• Frequency: May vary based on your child’s health so ask your doctor; considered part of wellness office visit

Who should get it: Sexually active adolescents 15 or older who are at increased risk of infection

• Description: Screening for chlamydia in sexually active adolescents
• Frequency: May vary based on your health so ask your doctor

Who should get it: Female adolescents who are sexually active or thinking about becoming sexually active

• Description: Education and counseling related to contraceptives and sterilization for women with reproductive capacity; surgical sterilization (except hysterectomies, which are not performed solely for sterilization)
• Frequency: May vary based on your child's health so ask your doctor
• More information:
  • Talk to your child's doctor to determine which of these contraceptive methods is right for her
  • Anesthesia services will pay at 100% only for sterilization
  • Certain services for contraceptive device insertion and removal, such as ultrasounds to confirm IUD placement will pay at 100%
  • Pregnancy tests prior to the initiation of contraceptive will pay at 100%
  • The following contraceptive methods (devices and associated procedures, such as device removal, and pharmaceutical contraceptives) for adolescent females with reproductive capacity:
    • Cervical caps
    • Diaphragms
    • Emergency contraception (e.g., morning after pill, Plan B, ella)
    • Fertility app
      • Effective 8.1.22, one annual subscription to Natural Cycles covered per benefit period. No additional supplies / services are covered. Natural Cycles is currently the only FDA-cleared fertility app.
      • Members must download the Member Claim Form (PDF) or the State Health Plan Claim Form (PDF) to submit and include the following:
        • the Natural Cycles receipt. Write the CPT code 99199 and diagnosis code Z30.8 on the receipt.
        • a prescription from an in-network provider that includes the name of the app, Natural Cycles fertility app
    • Injections (only covered as preventive for Medoxyprogesterone Acetate 150 mg, which is the only drug and dosage used for contraception)
    • Implantable rods
    • IUDs
    • Oral contraceptives (all generic contraceptives will be covered as preventive; brand oral contraceptives will continue to require member cost sharing (e.g., deductible, copay, and/or coinsurance) View a complete list of preventive oral contraceptives
    • OTC contraceptives (female condoms, all products; sponges, all products; spermicides, all products, male condoms effective 1.1.23)
    • Sterilization procedures including tubal ligation (tying of fallopian tubes) and salpingectomy (removal of fallopian tubes). Salpingectomy for sterilization purposes will be covered as preventive effective 7.1.22
    • Trans-dermal contraceptives (e.g., contraceptive patches)
    • Vaginal rings (e.g., Nuvaring)
  • Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider
  • If there is a medical reason you cannot take a generic contraceptive, your doctor should review this ACA copay waiver criteria form (PDF); if you meet these criteria, they can submit this information on the ACA copay waiver form (PDF).
• Exclusions:
  • Sterilization coverage applies to all places of service, with the exception of the Emergency Room; separately billed services are not covered under preventive services and are subject to the normal benefits based on place of service
  • Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription

Who should get it: Adolescents from age 12

• Description: Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years
• Frequency: May vary based on your child’s health so ask your doctor; part of any problem or preventive office visit

Who should get it: Sexually active adolescents 15 or older who are at increased risk of infection

• Description: Screening for gonorrhea in sexually active adolescents
• Frequency: May vary based on your health so ask your doctor

Who should get it: Adolescents at high risk of infection

• Description: Screening for Hepatitis B in adolescents at high risk of infection
• Frequency: May vary based on your health so ask your doctor

Who should get it: Adolescents at high risk of acquiring HIV

• Description: Offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition
• More information: Medications covered at 100%: emtricitabine/tenofovir (generic Truvada). For members who are clinically unable to utilize generic Truvada, brand Truvada, Viread, or Descovy may be made available by completing the copay waiver form (PDF) and faxing it to the number on the bottom of this document.
• Frequency: May vary based on your health so ask your doctor
• Effective: at renewal on or after July 1, 2020

Who should get it: Adolescents age 15 and older or younger if at increased risk

• Description: Screening for Human Immunodeficiency Virus (HIV). Younger adolescents who are at increased risk should also be screened
• Frequency: May vary based on your health so ask your doctor

The following are the recommended vaccines for adolescents and teens 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.

• COVID-19
• Human papillomavirus (HPV)
• Influenza (flu)
• Meningococcal
• Tetanus, diphtheria, acellular pertussis (Tdap)

Who should get it: Female adolescents

• Description: Doctor should provide or refer women who screen positive to intervention services
• Frequency: At least annually

Who should get it: Children age 6 or older

• Description: Screening for obesity; doctor should offer/refer to comprehensive, intensive behavioral interventions to promote improvement in weight status
• Frequency: May vary based on your child’s health so ask your doctor
• More information: Includes 30 nutritional counseling visits

Who should get it: Sexually active adolescents or teens

• Description: Behavioral counseling for sexually active adolescents and teens at increased risk for sexually transmitted infections (STIs)
• Frequency: May vary based on your child’s health so ask your doctor

Who should get it: Adolescents 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

Who should get it: School-aged children or adolescents

• Description: Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents
• Frequency: May vary based on your child’s health so ask your doctor
• Exclusions: Applicable only for members over age 5

Who should get it: Female adolescents

• Description: For female adolescents to get recommended preventive services that are age and developmentally appropriate. This well-child visit should, where appropriate, include other preventive services listed on this page.
• Frequency: Annual, although Health and Human Services recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on an adolescent's health status, health needs and other risk factors.