Find out which services for children are covered at 100%.
The age and frequency listed are general recommendations. Talk to your doctor to find out which of these your child should have based on their health.
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 August 1, 2022, 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) to submit and include the following:
- a prescription from an in-network provider that includes the name of the app, Natural Cycles fertility app
- the Natural Cycles receipt: As of April 1, 2024, write the CPT code 99199 and diagnosis code Z30.8 on the receipt. Prior to April 1, 2024, use 99199 as the CPT code and the diagnosis code, Z30.8.
- 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: 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®.
- If either of these two scenarios apply to you, have your provider fill out and fax the ACA Copay Waiver 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: 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
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)
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