Preventive Services

The Patient Protection and Affordable Care Act (PPACA), also known as Health Care Reform (HCR), was signed into law on March 23, 2010.

Within the legislation, there is a requirement to cover certain preventive care services and tests in full, as long as they are administered by in-network providers. Tufts Health Plan has implemented the preventive care requirements for all our plans that are not “grandfathered” and for those customers who wish to comply with the rule voluntarily.

The following lists the specified preventive care services covered without copayments, deductibles, or coinsurance (as long as they are administered by in-network providers). Preventive care services as specified by the U.S. Preventive Services Task Force, Centers for Disease Control and Prevention, and the Health Resources and Services Administration. This information is based on Tufts Health Plan’s review of the national health care reform legislation. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. Analysis is ongoing, and additional guidance is also anticipated from the Department of Health and Human Services. This list is subject to change.
 

Screenings

  • Asymptomatic Bacteria: Screening - Pregnant women
  • Cervical Cancer: Screening - Women who are sexually active
  • Chlamydia: Screening - Women ages 24 and younger or 25 and older at increased risk
  • Colorectal Cancer: Screening - Adults, beginning at 50 and continuing until 75
  • HIV: Screening - Adults and adolescents at increased risk
  • HIV: Screening - Pregnant women
  • Hepatitis B Virus: Screening - Pregnant women
  • Lipid Disorders in Adults: Screening - Men 35 and older
  • Lipid Disorders in Adults: Screening - Women 45 and older, increased risk for CHD
  • Rh(D) Blood Typing: Screening - Pregnant women, first pregnancy-related visit
  • Syphilis: Screening - Pregnant women
  • Syphilis: Screening - Men and women at increased risk
  • Abdominal Aortic Aneurysm: Screening - Men 65-75, smoker
  • Breast Cancer: Screening with mammography - Women 50-74 years
  • Depression: Screening - Adolescents, 12-18 years old, in clinical practices with systems of care
  • Depression: Screening - Adults 18 and over, when staff-assisted depression care supports are in place
  • Gonorrhea: Screening - Pregnant women and women at increased risk
  • Iron Deficiency Anemia: Screening - Asymptomatic pregnant women
  • Lipid Disorders in Adults: Screening - Men 20-34, increased risk for CHD
  • Lipid Disorders in Adults: Screening - Women 20-44, increased risk for CHD
  • Obesity: Screening - Children and adolescents, ages 6-17
  • Osteoporosis: Screening - Postmenopausal women 65 years and older with no risk factors, or 60 years and older with risk factors
  • Rh(D) Blood Typing: Screening - Antibody testing unsensitized Rh(D) - Negative pregnant women
  • Type 2 Diabetes Mellitus: Screening - Men and women with sustained BP 135/80+
  • Visual Impairment: Screening - Children younger than 5 years

Pediatric Screenings

  • History (initial/interval); Measurements (length/height and weight; head circumference; weight for length, body mass index, blood pressure); Sensory Screening (vision; hearing)
  • Developmental/Behavioral Assessment (developmental screening; autism screening; developmental surveillance; psychological/behavioral assessment; alcohol and drug assessment)
  • Physical Examination
  • Newborn Metabolic/Hemoglobin Screening
  • Hemocrit or Hemoglobin
  • Lead Screening
  • Tuberculin Test
  • Dyslipidemia Screening
  • STI Screening
  • Cervical Dysplasia Screening

Counseling Services

  • Tobacco Use: Counseling and intervention for adults
  • Tobacco Use: Counseling and intervention for pregnant women
  • Aspirin to Prevent CVD: Women ages 55 to 79, to prevent ischemic strokes
  • Aspirin to Prevent CVD: Men ages 45 to 79, to prevent myocardial infarctions
  • Alcohol Misuse: Screening and behavioral counseling - Men, women, pregnant women
  • BRCA mutation counseling related to BRCA screening
  • Breast Cancer: Preventive medication discussion - Women, increased risk
  • Healthy Diet: Counseling - Adults with hyperlipidemia and other risk factors for CVD
  • Obesity: Screening and intensive counseling - Obese men and women
  • Sexually Transmitted Infections: Behavioral counseling - Sexually active adolescents and adults at increased risk

Immunizations

  • Rotavirus
  • DTP
  • Haemophilus influenzae Type B
  • Inactivated poliovirus
  • MMR
  • Meningococcal
  • HPV
  • Tetanus, diphtheria, pertussis
  • Human papillomavirus
  • Varicella
  • Zoster
  • Measles, mumps, rubella
  • Influenza
  • Pneumococcal (polysaccharide and conjugated)
  • Hepatitis A
  • Hepatitis B
  • Meningococcal

Women's Preventive Health

  • Well-woman visits
  • Screening for gestational diabetes
  • Human papillomavirus (HPV) DNA testing for women 30 years and older
  • Sexually transmitted infections (STI) counseling, and HIV screening and counseling
  • FDA-approved contraception methods and contraceptive counseling
  • Breastfeeding support, supplies, and counseling
  • Domestic violence screening and counseling
  • Surgical Contraceptive Procedures

Medications

Name Applies to Special Coverage Considerations
Asprin 81 mg OTC Generic Only Covered in full for women of childbearing age (12-52 years)
Asprin ≤ 325 mg OTC Generic Only Covered in full for members age 45 years and older
Bowel preparations -- Brand names: Moviprep, Prepopik, Suclear, and Suprep. Generics: gavilyte-H, peg-prep Rx Brands* and Generics Covered in full generic and single-source brand bowel preparations for members age 50 - 74 years old
Fluoride drops and tablets Rx Brands and Generics Covered in full for preschool childres age 6 months through age 6
Folic acid 0.4 mg, 0.8 mg, 1 mg OTC Brands and Generics Covered in full for women of childvearing age (12-52 years)
Iron liquid supplements OTC Brands and Generics Covered in full for children up to 12 months of age
Preventive medications for the risk reduction of primary breast cancer in women: Evista, raloxifene, Soltamox, tamoxifen Rx Brands and Generics Covered in full for women
Prescription smoking cessation products Rx Brands and Generics Covered in full
Vitamin D 400 unit capsules, drops and tablets; 400 unitl/mL oral liquid; 1,000 unit/10 mL oral liquid; 1,200 unit/15 mL oral liquid OTC Brands and Generics Covered in full for members age 65 years and older


*Brand-name medications are covered in full until a generic is available

Under the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or health care reform, these preventive medications may be covered at no cost (copay, coinsurance, or deductible) for Tufts Health Plan members, depending on their plan benefits. Please check the specific terms of your plan benefit document.

The covered preventive medications must be prescribed by a licensed provider and filled at a network pharmacy. Please see Special Coverage Considerations for coverage limitations such as age and gender rules.

Note: A prescription is required for all listed medications, including over-the-counter (OTC) medications and contraceptives.

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