Preventive Care
Well-Child Care
Benefits are provided for well-child care services for covered dependents up to age 18 at 100 percent. These services are not subject to the calendar year deductible. Benefits are only provided when a network provider renders the service, and the wellness services are filed with a wellness diagnosis.
Well-newborn nursery care while a newborn is hospital-confined after birth is covered at 100 percent. This includes room, board, and other normal care provided by a network hospital or provider.
Well-child office visits, certain diagnostic tests, and immunizations are also covered at 100 percent.
Wellness/Preventive Coverage for Adults
Benefits are provided at 100 percent of the allowable charge for up to two office visits per calendar year and certain diagnostic tests and immunizations. These are based on the participant's age and gender. These services are not subject to the calendar year deductible.
Wellness and preventive care benefits are only provided when a network provider renders the service and the wellness services are filed with a wellness diagnosis. Visit State and School Employees’ Health Insurance Plan for a list of covered preventive services.
Wellness/Preventive Prescriptions
In line with health care reform, benefits for the following items are provided at 100 percent of the allowable charge and are not subject to the calendar year or prescription drug deductible. A prescription is required for all preventive medications provided at 100 percent of the allowable charge:
Low-dose aspirin (81mg/day) after 12 weeks of gestation for women who are at high risk for preeclampsia, 12-59 years old
Fluoride supplements for children 5 years or younger
Folic acid supplements for female participants 55 years or younger
Iron supplements for children ages 6 – 12 months old
Generic statins (Lovastatin/pravastatin) for participants without a history of cardiovascular disease (CVD), 40 - 75 years old with one or more CVD risk factors with a 10-year cardiovascular event risk factor of 10 percent or greater
Generic bowel prep medications for colonoscopy procedures in participants 45-75 years old
Infant eye ointment for the prevention of gonococcal eye infections (for newborns) up to age 3 months
HIV Pre-Exposure Prophylaxis
Certain preventive medications for women 35 years or older who are at an increased risk for breast cancer
A complete list of the covered preventive prescriptions can be found at Caremark or by calling CVS Caremark Customer Care at 888-996-0050.
Contraceptives
Coverage is provided to female participants for prescription contraceptives and other U.S. Food and Drug Administration (FDA) approved contraceptive methods. A prescription is required. Benefits for certain generic contraceptives will be provided at 100 percent and are not subject to the calendar year deductible.
Refer to the CVS Caremark ACA Drug list at Caremark for specific covered drugs. Brand contraceptives are subject to the calendar year deductible and the applicable copayment except in situations where there is no generic available within that specific method as identified by the FDA, or in situations where the generic within that specific method is not medically appropriate as determined by the participant's provider.
Breast-Feeding Support, Supplies, and Counseling
Benefits are provided for breast-feeding support, supplies, and counseling in conjunction with each childbirth. This includes comprehensive lactation support and counseling by a trained provider during pregnancy and/or postpartum.
The purchase of a manual breast-feeding pump is covered at 100 percent, not subject to the calendar year deductible. The purchase or rental of an electronic breast-feeding pump is covered up to $100, not subject to the calendar year deductible.
Breast-feeding pumps and pump supplies may be purchased through a durable medical equipment (DME) company or at a retail store. In most cases, you will be required to pre-pay for the equipment and file a claim for reimbursement. Submit a copy of the receipt with a claim form to be reimbursed at the Plan allowance for these supplies.