Skip to main content

List of what's covered

Cancer screenings and counseling

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

Description: Counseling young adults, adolescents, children, and parents of young children about minimizing exposure to UV radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer.

Frequency: May vary based on your health, so ask your doctor.

  • Who should get it: Women age 40 or older
  • Description: Screening for breast cancer in women over 40
  • Frequency: Every 1 to 2 years, with or without clinical breast examination
  • More information: Effective 6.1.17, 3D mammography screening will be a covered service

  • Who should get it: Women age 21 to 65
  • Description: Screening for cervical cancer
  • Frequency:
    • In women age 21 to 29 with cervical cytology (Pap test) every 3 years
    • For women age 30 to 65
      • A Pap test every 3 years, or
      • A Pap test and high-risk human papillomavirus (hrHPV) test every 5 years, or
      • hrHPV test only every 5 years

  • Who should get it: Women ages 45 to 75
  • Description: Screening for colon/colorectal cancer in adults age 45 to 75 Effective no later than April 1, 2022, colorectal cancer screening and associated services are covered at 100% for eligible members aged 45 or older.
  • Frequency: Using fecal blood testing (gFOBT or FIT) annually, Cologuard every 3 years, sigmoidoscopy or CT/virtual colonography every 5 years, or colonoscopy every 10 years. These tests are available in network.
  • More information:
    • If you have a positive fecal blood test (gFOBT or FIT or Cologuard) or visualization test (CT colonography or sigmoidoscopy), your doctor may order a follow up colonoscopy. Starting June 1, 2022, this follow up colonoscopy will be covered at 100%.
    • If you had a polyps removed during a previous preventive screening colonoscopy, future colonoscopies will be covered but may not be considered preventive so you may have out of pocket costs.
    • Your doctor may order a colonoscopy more frequently than every 10 years. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs.
    • Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%.
    • Provider consultation prior to the colonoscopy procedure is covered at 100%.
    • Certain bowel preparation medications for a screening colonoscopy are covered at 100% when prescribed by a doctor.
    • If there is a medical reason you cannot use a generic bowel preparation medication, your doctor should review this ACA Copay Waiver Criteria (PDF); if you meet these criteria, they can submit this information on the ACA Copay Waiver form (PDF).
    • Barium enema is a covered service but not at 100% so you may have out of pocket costs.   

Who should get it: Age 50 to 80 and high risk due to smoking or other exposure

  • Description: Annual screening for lung cancer with low-dose Computed Tomography scan in adults ages 50 to 80 years who have a 20-pack-per-year smoking history and currently smoke or have quit within the past 15 years
  • Frequency: Annually if you qualify as high risk
  • More information: Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery

Additional services for women at high risk of breast cancer

Who should get it: Women who have personal or family history of breast, ovarian, tubal or peritoneal cancer or ancestry associated with breast cancer susceptibility

  • Description: Assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool.
  • Frequency: May vary based on your health so ask your doctor. However, women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.

Who should get it: High-risk women age 35 or older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ

  • Description: Clinicians should offer to prescribe risk reducing medications such as tamoxifen, raloxifen or aromatase inhibitors (anastrozole) to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
  • Frequency: May vary based on your health so ask your doctor
  • Exclusions: Applies to asymptomatic women aged 35 years or older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ; generic risk-reducing medications are covered as preventive
  • More information: For members who have swallowing problems or may have an intolerance to generic products, brand products may also be made available by completing the ACA Copay Waiver form (PDF) and faxing it to the number on the bottom of the document.

Disease prevention and heart health

Who should get it: Adults aged 35 to 70 who are overweight or obese; certain women after pregnancy

  • For adults aged 35 to 70: Screening for prediabetes and type 2 diabetes for adults aged 35 to 70 who have overweight or obesity. Clinicians should offer or refer patients with prediabetes or type 2 diabetes to effective preventive interventions.
    Frequency: May vary based on your health so ask your doctor
  • For women with a history of gestational diabetes who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes.
    Frequency: Initial testing 3 should ideally occur within the first year postpartum and can be conducted as early as 4 to 6 weeks postpartum.

Who should get it: Age 18 or older

  • Description: Screening for high blood pressure, or hypertension, in adults with office blood pressure measurement. Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
  • Frequency: May vary based on your health so ask your doctor.
  • More information: Effective January 1, 2017, blood pressure monitors will be covered at 100% for members who have an elevated blood pressure during their doctor's visit, but have not been diagnosed with high blood pressure. This will cover ambulatory blood pressure monitors and home blood pressure monitors. Home blood pressure monitors must be purchased from an in-network DME provider. To find a DME provider, use our Find Care tool.

Who should get it: Age 18 or older if at increased risk

  • Description: Screening for latent tuberculosis in populations at increased risk.
  • Frequency: May vary based on your health so talk to your doctor.

Who should get it: Women age 65 or older, younger high-risk women

  • Description: For women 65 years or older: Screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures. For women younger than 65: screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool.
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Adults aged 40 to 75 with certain risk factors

  • Description: Statins for the primary prevention of CVD in adults aged 40 to 75 years who have one or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD event risk of 10% or greater. Screening for high cholesterol is also covered.
  • More Information:
    • Medications covered at 100%: Lovastatin (20 or 40 mg) or Pravastatin (10, 20, 40 or 80 mg). If there is a medical reason you cannot use a generic statin, your doctor should review the ACA Copay Waiver Criteria (PDF); if you meet these criteria, they can submit this information on the ACA Copay Waiver form (PDF)
    • Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD.

Pregnancy and childbirth

Who should get it: Pregnant adults

  • 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 doctor

Who should get it: Pregnant women/women who have delivered a baby recently

  • Description: Interventions during pregnancy and after birth to promote and support breastfeeding; comprehensive lactation (breastfeeding) support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for breastfeeding equipment (see Exclusions)
  • Frequency: May vary based on your health so ask your doctor
  • More information: Counseling covered at 100% through in-network providers (i.e., OB/GYNs, midwives, facilities)
    • Certain breast pumps for pregnant and post-partum women
      • One manual or electric breast pump purchase per pregnancy is covered
      • Benefit available during third trimester (starting 11.1.16) or after member has delivered the baby
      • Breast pumps come with certain supplies, such as tubing, shields and bottles
      • Additional replacement supplies are not covered with the initial breast pump purchase. Replacement supplies are only covered after the breast pump has been purchased and are limited to 2 of each supply per year.
      • Breast pumps must be purchased from participating Durable Medical Equipment (DME) vendors

Exclusions: All other supplies are excluded (i.e., creams, nursing bras, milk storage bags); hospital-grade breast pumps are excluded and not covered

 

Who should get it: Pregnant women

  • Description: Screen for gestational diabetes in asymptomatic pregnant women at 24 weeks of gestation or after
  • Frequency: Once, any time after 24 weeks’ gestation (ideally 24 to 28 weeks)

Who should get it: Pregnant women

  • Description: Screen all pregnant women for HIV including those how present in labor who are untested and whose HIV status is unknown
  • Frequency: May vary based on your health so talk to your doctor

Who should get it: Pregnant women at high risk for Preeclampsia

  • Description: Use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks’ gestation
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Pregnant or postpartum women

  • Description:
    • Screening for depression in postpartum women.
    • Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.
  • Frequency for screening postpartum women: At 1, 2, 4, and 6-month infant visits

Who should get it: Pregnant women

  • Description: Screen for preeclampsia with blood pressure measurements throughout pregnancy
  • Frequency: During each prenatal care visit

Who should get it: Pregnant women

  • Description: Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care
    • Recommended repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks’ gestation unless the biological father is known to be Rh (D)-negative
  • Frequency: Twice — at first pregnancy visit and again at 24 to 28 weeks’ gestation (if qualified)
  • More Information: Initial testing is part of the obstetric panel

Who should get it: Pregnant women 

  • Description: Screening for asymptomatic bacteriuria with urine culture
  • Frequency: Once at 12 to 16 weeks’ gestation or at first prenatal visit, if later

Who should get it: Women planning or capable of pregnancy

  • Description: Women to take a daily supplement containing 0.4 to 0.8 mg (400 to 800mcg) of folic acid
  • Frequency: May vary based on your health so ask your doctor
  • Exclusions: Over-the-counter (OTC) folic acid supplements are only covered with a prescription

Mental health and substance abuse

Who should get it: Adult women

  • Description: Screening for anxiety in adult women, including those who are pregnant or postpartum.
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Age 18 or older, including pregnant women

  • Description: Screen adults for unhealthy alcohol use and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Age 18 or older

  • Description: Ask questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.)
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Age 18 or older

  • Description: Screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up
  • Frequency: Part of any problem or preventive office visit

Who should get it: Women of reproductive age

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

Who should get it: Age 18 or older; when pregnant

  • Description: Ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco
  • Frequency: May vary based on your health so ask your doctor
  • More Information:
    • Telephonic counseling available by calling QuitlineNC at 844-8NCQUIT (844-862-7848).
    • FDA-approved tobacco cessation prescription medications and OTC nicotine replacement therapy (NRT)(PDF) covered at 100%.
      • NRT through QuitlineNC is available without a prescription. Members must enroll in the multi-call program to qualify for up to 12 weeks of NRT. Limited to a 90-day supply each for two cessation efforts.
      • NRT through the pharmacy benefit is available only with a prescription.
      • No prescription medication or NRT limit when received via pharmacy benefit

Sexual health

Who should get it: Sexually active women 24 years or younger and in women 25 years or older who are at increased risk of infection

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

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

  • Description: All FDA approved contraceptive methods, sterilization procedures, education and counseling related to contraceptives
  • Frequency: May vary based on your health so ask your doctor
  • More information:
    • 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 women with reproductive capacity:
      • Cervical caps
      • Diaphragms
      • Emergency contraception (i.e., 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 (PDF).
      • 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 (i.e., contraceptive patches)
      • Vaginal rings (i.e., 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 (PDF); if you meet these criteria, they can submit this information on the ACA Copay Waiver form (PDF).
    • Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription
  • Exclusions:
    • Hysterectomies are not performed solely for sterilization so are not covered as preventive.
    • Place of service exclusion: 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

What is a religious organization: A religious organization refers to all employer groups defined under federal law that may limit or not cover contraceptive services due to the type of organization or that have a religious objection to these services.

Some Blue Cross NC members who are employees of religious organizations and their dependents:

  • may not have contraceptive benefits
  • may have them as a covered benefit, but not as a preventive care benefit covered at 100%
  • may not have contraceptive benefits through your group medical plan
  • may have coverage through a separate contraception-only policy

Talk to your employer or check your benefit booklet to confirm your coverage for these benefits and any limitations.

Who should get it: Sexually active women 24 years or younger and in women 25 years or older who are at increased risk of infection

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

Who should get it: Women at high risk of infection or pregnant women

  • Description: Screening for Hepatitis B in adults at high risk of infection or in pregnant women at their first prenatal visit
  • Frequency: May vary based on your health so ask your doctor. For pregnant women at their first prenatal visit.

Who should get it: Women aged 18 to 79

  • Description: Screening for Hepatitis C in adults aged 18 to 79.
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Persons 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) and Apretude (under medical benefit)
    • If either of these two scenarios apply to you, have your provider fill out and fax the ACA Copay Waiver form (PDF) 
      1. Scenario 1: Brand Truvada, Viread, or Descovy may be made available if you are clinically unable to use generic Truvada.
      2. Scenario 2: Your claim for emtricitabine/tenofovir (generic Truvada) or Apretude 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: Women to age 65 or older if at increased risk

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

Who should get it: Sexually active women

  • Description: Behavioral counseling for sexually active women
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Women at high risk of infection and pregnant women

  • Description: Screening for syphilis in those at increased risk of infection or in pregnant women
  • Frequency: May vary based on your health so ask your doctor

Nutrition and wellness

Who should get it: Age 65 or older

  • Description: Exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
  • Frequency: May vary based on your health so ask your doctor

Who should get it: Adults with cardiovascular risk factors

  • Description: Offer or refer adults with cardiovascular disease (CVD) risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
  • Frequency: May vary based on your health so ask your doctor
  • More Information: Preventive care includes 4 treatments provided by a physician and 30 nutritional counseling visits by a licensed dietitians or nutritionist

Who should get it: Age 18 or older

  • Description: If your body mass index (BMI) is 30 or higher, your doctor should refer you to or offer you intensive, multi-component behavioral interventions
  • Frequency: May vary based on your health so ask your doctor
  • More information: Preventive care includes 4 treatments provided by a physician and 30 nutritional counseling visits by a licensed dietician or nutritionist

Who should get it: All women

  • Description: Screening should assess whether women experience urinary incontinence and whether it impacts their activities and quality of life. Clinicians should refer women for further evaluation and treatment if indicated
  • Frequency: Annual

Who should get it: Women, dependent children up to age 26, pregnant women

  • Description: For women and dependent children to get recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care specified as preventive on this site regardless of whether the member has maternity coverage; this well-woman 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 a woman's health status, health needs and other risk factors

Who should get it: Women aged 40 to 60 years with normal or overweight body mass index (BMI) of 18.5 to 29.9

  • Description: Counseling to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity
  • Frequency: May vary based on your health so ask your doctor

Immunizations

The following are the recommended vaccines for women 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 for more information.

  • COVID-19
  • Haemophilus influenza type b
  • Herpes Zoster (Shingles)
  • Hepatitis A
  • Hepatitis B
  • Human papillomavirus (HPV)
  • Influenza (Flu)
  • Measles, mumps, rubella (MMR)
  • Meningococcal
  • Pneumonia
  • RSV (Respiratory Syncytial Virus)
  • Tetanus-Diphtheria/Tetanus-Diphtheria Acellular Pertussis (Tdap)
  • Varicella (Chicken Pox)

Medications

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)