Blue Cross/Blue Shield Preventive Services With NO Out-of-Pocket Expense
Beginning January 2012
Precertification: Not required.
Your Cost-Share:
All preventive services, except for mammography, foreign travel immunizations,
nutritional counseling and training, and routine vision exams for members under
age 5, must be received from in-network providers or the services will not be
covered.
Your cost-share is waived, regardless of the location where services are provided, if:

you receive one of the services listed in the Benefit Description subsection of this
Preventive Services section; and

the combination of procedure codes and diagnosis codes billed by your provider on
the line of the claim indicates the service is preventive.
If you receive mammography or foreign travel immunization services from a
noncontracted provider, you pay the balance bill. See the cost-share for members under
age 5 under the “Vision Exams (Routine)” and the cost-share for “Nutritional Counseling
and Training” under “Education and Training” for the cost-shares applicable to these
preventive services.
For more information on the foreign travel immunizations covered under this benefit, go
to the Medical Coverage Guidelines available at www.azblue.com/member, or call
BCBSAZ Customer Service.
Benefit-Specific Definition: “Preventive services” are those services performed for screening
purposes when you do not have active signs or symptoms of a condition. Preventive services do
not include diagnostic tests performed because the member has a condition or an active
symptom of a condition, which is determined by the combination of procedure and diagnosis
codes your provider submits on the claim.
Benefit Description: Benefits are available for the following services, as appropriate for the
member’s age and gender and as recommended by your provider:

Preventive physical examination, i.e. routine physical examination, including the following
services when done for screening purposes only:

Resting electrocardiogram (EKG)

Lung function test (spirometry)

Vision and hearing screening (this may include newborn audiological evaluation in the
hospital)

Fecal occult blood test

General health laboratory panel (bilirubin, calcium, carbon dioxide, chloride, creatinine,
alkaline phosphatase, potassium, total protein, sodium, ALT, SGPT, AST, SGOT, BUN, TSH)

Thyroid function testing (TSH)

Complete blood count (CBC)

Lipid panel (cholesterol panel and triglycerides)

Fasting glucose (blood sugar)

Urinalysis

Blood lead

Sexually transmitted disease (STD) testing

Prostate specific antigen (PSA)

TB testing

Screening for abdominal aortic aneurysm for men ages 65 to 75 who have ever smoked

Routine gynecologic exam including Pap test and other cervical cancer screening test

Mammogram

Bone density testing for osteoporosis

Screening sigmoidoscopy or colonoscopy

Routine immunizations and immunizations for foreign travel, as determined by BCBSAZ

Folic acid supplementation prescribed for females

Aspirin prescribed for prevention of cardiovascular disease for men ages 45 to 79 and
women ages 55 to 79

Behavioral intervention to promote breast-feeding for women

Oral fluoride supplementation prescribed for children ages 6 months through 5 years who live
in areas where the water service is deficient in fluoride

Depression screening for members age 18 and older

Screening for major depressive disorders for members ages 12 through 18

Routine iron supplementation prescribed for asymptomatic children ages 6 months through
12 months who are at increased risk for iron deficiency anemia

Routine screening for iron deficiency anemia for asymptomatic pregnant women

Counseling and behavioral interventions to promote sustained weight loss for obese adults

Tobacco cessation counseling and augmented pregnancy counseling for members who use
tobacco

Newborn screenings as required by Arizona and federal law

Vision screenings for children under age 5

Alcohol misuse screening and behavioral counseling interventions for pregnant women

Screening for asymptomatic bacteriuria for pregnant women at 12-16 weeks gestation or at
first prenatal visit, if later

Screening for Hepatitis B virus infection for pregnant women at their first prenatal visit

Screening for Rh(D) incompatibility through blood typing and antibody testing for pregnant
women at their first prenatal visit

Repeated antibody testing for unsensitized Rh(D)-negative pregnant women at 24-28 weeks
gestation, unless the biological father is known to be Rh(D) negative

Smoking cessation medication and devices, as prescribed
Benefit-Specific Exclusions:
Services from an out-of-network provider (except for mammography services, routine vision
exams for members under age 5, nutritional counseling and training, and foreign travel
immunizations). Routine immunizations received from an out-of-network provider are not covered.
Except for nutritional counseling and training and routine vision exams for members under age 5,
any service or test not specifically listed in this benefit description, such as chest X-rays, will not
be covered when performed for preventive or screening purposes
Services or tests listed under this benefit and provided to a member with a specific diagnosis,
signs or symptoms of a condition or disease for which the test is being performed may be
covered through another benefit section of this plan. Certain maternity services covered under
this benefit are also available through the “Maternity” benefit.