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Preventive care at no cost to you* when you see an in-network provider.
What is Preventive Care?
Preventive health care refers to proactive measures taken to maintain and improve an individual’s overall well-being and prevent the onset of illness or disease.
It involves a range of practices and strategies aimed at identifying potential health risks early on, promoting healthy lifestyles, and minimizing the likelihood of developing certain conditions.
Preventive health care includes regular check-ups, vaccinations, screenings, and diagnostic tests that help detect any signs of disease at an early stage when treatment is most effective.
Additionally, adopting healthy habits such as exercising regularly, maintaining a balanced diet, managing stress levels, and avoiding harmful substances like tobacco and excessive alcohol consumption are key components of preventive health care.
By prioritizing prevention, individuals can actively protect and enhance their health, leading to a higher quality of life and reduced healthcare costs in the long run.
- Always fully covered with in-network providers
- BEFORE symptoms arise
- Based on age or risk factors
- Routine
- Recommended
Preventive care catches problems early to help you stay healthy.
This includes routine checkups, screenings, and tests recommended because of your age or risk factors.
Example
A colonoscopy done at the recommended age before you have symptoms is considered preventive care.
Preventive Definitions of your plan:
Preventive health care services for health care screenings or preventive purposes submitted with a preventive diagnosis will be covered at 100% of the allowable fee.
Preventive procedures include those with an A or B rating on the link to the United States Preventive Services Task Force website. Search procedure.
Include an initial preventive procedure found with an A or B rating and billed with a preventive diagnosis code.
Preventive health care services rendered for an established medical condition will be subject to the plan’s deductible, coinsurance, copayment, and annual maximum out-of-pocket.
- Subject to plan; not automatically covered
- AFTER symptoms arise
- Based on symptoms
- Specifically ordered
- Required for treatment
Diagnostic care is used to find out what’s causing symptoms or health concerns.
Example:
If a colonoscopy is ordered because you’re having symptoms, it’s considered diagnostic care.
Important
Diagnostic care is not covered under preventive benefits.
You may be responsible for copays, coinsurance, or your deductible.
Medical and Diagnostic:
Follow up lab tests or procedure codes that are billed with diagnostic medical diagnosis codes.
Any procedure, laboratory test, scan, imaging service- including MRI or ultrasound, biopsy, and pathology that is diagnostic in nature, billed with a diagnostic medical code, and not inclusive of the list of preventive care services.
Medical and Diagnostic services are subject to deductible, coinsurance, copayment and annual maximum out-of-pocket.
Preventive health care is much more than your annual doctor visit.
Health screenings, certain medications, vaccinations, and lifestyle counseling are all examples of Preventive Care.
Preventive care helps you catch health changes at an early stage when treatment is most effective. Check your Outline of Coverage for details and consult your doctor.
What counts as preventive?
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk. Statin medications.
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Pregnancy & Planning
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits (PDF, 1.5 MB)
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Bilirubin concentration screening (PDF, 609 KB) for newborns
- Blood pressure screening for children: Age 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings (PDF, 609 KB) for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements (PDF, 609 KB) taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for Adults
Doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
For Children
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
$0 out-of-pocket Drugs & Supplies
No need to ration prescriptions and supplies. Or choose between medicine refills or gas refuels.
These drugs are $0 for Members.
Do you take medications in one of the categories listed below?
Our $0 Out-of-Pocket Drug List covers specific drugs in these categories even if you haven’t met your deductible or annual out-of-pocket expense.
This means that CO-OP members will not have any cost-share for medications listed this preventive drug list.
$0 Out-of-Pocket Drug Categories:
- Anticoagulant Medications
- Antidepressant Medications
- Blood Glucose Meter
- Bone Medications
- Cardiovascular Medications
- Cholesterol Medications
- Continuous Glucose Monitor
- Diabetic Medications
- Diabetic Supplies
- Diabetic Test Strips
- Respiratory Medications
Get prescription drugs delivered to your home.
Visit Birdi to set up your profile.
Set up a profile on Birdi using the Rx information off your member benefits card.
Pharmacy Mail Order – Instructions
*NoviXus is now known as Birdi
Mental Health & Lifestyle Counseling
24/7 access to Behavioral Healthcare
All mental health services are available via Doctor On Demand at anytime.
Depression screening for adolescents beginning routinely at age 12
Many medications for depression and mood regulation.
Nutrition counseling for adults at higher risk for chronic disease
Fall prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
Fine print
*Preventive Health Care services are covered at 100%, with no out of pocket costs when contracting provider networks are used. Any services performed with an Out of Network Provider will result in copayments, deductibles, and cost-sharing and may result in balance billing. Your doctor must write a prescription for preventive medication services to be covered by your plan, even if they are listed as over the counter. Frequency limitations may apply to to preventive care services such as screenings. Diagnostic tests (blood work, imaging) are not considered preventive. Networks may vary by plan. Please use the Provider Finder to find the providers for your network.
MHC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age disability, or sex.
Q & A
If you are enrolled in a Mountain Health CO-OP Insurance Plan, you are eligible for 100% coverage for wellness or preventive services*.
To learn more about your preventive benefits, call the number on the back of your ID card to talk to a customer service agent about your benefits.
Services that are listed in your member benefit plan document (Summary of Benefits and Coverage) under “preventive health benefits” are covered at 100%*.
This means that you have no out of pocket cost. You do not have to pay a copay, deductible, or co-insurance to have these services done when you see an in-network doctor, laboratory, hospital, or durable medical equipment provider.
You may have to pay your deductible, copay, and coinsurance if you choose to have these services by an out-of-network doctor, laboratory, hospital, or durable medical equipment provider.
If you need help finding an in-network doctor, call the number on the back of your ID card, and Member Service can help you. Or search for a provider.
Preventive care is the health care that you get to prevent illness, detect medical conditions, and keep you healthy.
For example, your doctor might want you to get a colonoscopy because of your age. However, if your doctor wants you to have a colonoscopy because of you are having symptoms like diarrhea or stomach pains, this is diagnostic care.
The diagnostic colonoscopy would not be paid under your preventive benefit, and you would be responsible for coinsurance, copayments, and your deductible.
Remember to ask your doctor if tests and procedures are preventive or diagnostic and if they are in-network with Mountain Health CO-OP.
Your annual wellness exam is one of the many preventive services that the CO-OP covers at 100%. However, some of the tests or procedures your doctor orders may not be covered under your preventive health benefit or your benefit plan.
If you have any questions about benefit coverage, call the number on the back of your ID card, and Customer Service can help you.
Mountain Health CO-OP supports federal and state government mandates to cover a wide range of preventive services. The CO-OP follows recommendations from government agencies to determine which services we include.
These recommendations can change, and the CO-OP regularly updates your benefits to reflect evidence-based practices. The CO-OP may adopt or change covered preventive service guidelines within the time required by law. Visit uspreventiveservicestaskforce.org/ for more information.
You can have preventive and non-preventive services in the same office visit.
For example, you may visit your doctor for an annual preventive/wellness exam. In the same visit, you may want to discuss a health concern (non-preventive care) such as a new knee injury.
Your office visit benefit may apply to the non-preventive part (knee injury) of your visit. In this scenario, your doctor will bill for the annual wellness exam AND a regular office exam because they took extra time to address your new problem, the knee injury.
You may be required to pay a copay, coinsurance, and deductibles for the regular office exam. The annual wellness/preventive part of the visit is still covered at 100%*.
There are many reasons why you may have received a bill for a visit. You may have seen an out-of-network doctor, the doctor may have billed MHC with codes that told us you were there for something other than an annual preventive exam, or the tests or services you had done were not covered by your health plan.
If this has happened to you, call us at the number on the back of your ID card and we can help you understand your bill.
You may choose any of the following types of providers as your primary care physician:
Family Practice, Internal Medicine, Pediatrician, Obstetrics and Gynecology, Gynecologist, Geriatrician, Osteopath, Nurse Practitioner, and/or Physician’s Assistant.
Resources for managing health conditions and finding effective treatment.
Including mental health services
available 24/7 via telehealth.
Advice & Guidance
How is your heart health?
Idaho: Breast Cancer Supplemental Screening Requirements
Adult Preventive Care
Children’s Preventive Care
Your Mental Health Matters
Men’s Preventive Health Care
Prepping for Cold and Flu Season
Colorectal Cancer Screenings
Managing Diabetes
Common Health Conditions Resources
Behavioral and Mental Resources
For more information or local resources, please click the links below.
Suicide Prevention & Crisis Intervention
Speak to a Counselor
You are not alone.
To speak to a counselor now, please call the Lifeline at 988.
Or text with a counselor via Lifeline chat (there may be a wait time to connect).
Help with Medications
Our clinical pharmacy management team and medical care management team work closely together to provide members with the best possible care while keeping costs low.
Discuss your pharmacy care
Care Management Team: 1-855-885-7695
- Focus on Overall Health
- Experienced Pharmacy Management Team
- National Pharmacy Network
- Customized Benefit Designs
- 24/7 Customer Service
- Online Member Tools
- Disease & Cost Management
- Mail Order & Specialty Pharmacy Services
Parents & Pregnancy
Are you pregnant?
If you have questions or concerns, or need help finding an OB/GYN our Care Management team can help: 800-299-6080
Resources for parents
Prescription Medications - Preventive Health Benefit
Your health plan may include certain prescription and over-the-counter (OTC) preventive medicines, as a benefit of membership, at no cost to you when you use a pharmacy or doctor in your health plan’s network. There is no co-pay, deductible or coinsurance, even if your deductible or out-of-pocket maximum has not been met.
In addition to the preventive medications outlined in the Affordable Care Act (ACA), effective January 1, 2021 the Co-Op will provide expanded coverage for hundreds of other preventive medications used to treat chronic illness at no cost to our members.
You will find that list of medications in our $0 Out-of-Pocket Drug List list for the current year and it will be available to all the individual and family plans, small group plans, and large group plans that the Co-Op offers.
Remember
Your doctor must write a prescription for these preventive services to be covered by your plan, even if they are listed as over-the-counter.
The ACA list and the $0 Out-of-Pocket Drug List include:
- Medicine and supplements to prevent certain health conditions for adults, women, and children
- Medicine and products for quitting smoking or chewing tobacco (tobacco cessation)
- Medicine used prior to screenings for certain health conditions in adults
- Vaccines and immunizations to prevent certain illnesses in infants, children, and adults
- Contraceptives for women
- Drugs for Asthma and COPD
- Drugs and blood glucose testing supplies to treat diabetes (including Insulins)
- Drugs to treat depression
- Drugs to treat osteoporosis
- Drugs to treat cardiovascular disease
- Drugs to lower cholesterol
- Drugs to treat coagulation disorders
ASPIRIN to help prevent serious heart and blood vessel problems (cardiovascular disease) and colorectal cancer in adults 50 to 59 years old who are at risk.
Generic dosage forms of 81 mg
Aspirin products (OTC):
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TOBACCO CESSATION PRODUCTS to help adults who are not pregnant quit tobacco use in order to prevent health problems. Tobacco use includes smoking or chewing tobacco.
Generic nicotine replacement products—patch, gum and lozenges
Brand-name Nicotrol (nicotine inhalation system)
Brand-name Nicotrol NS (nicotine nasal spray)
Generic bupropion (generic of brand-name, Zyban)—Zyban is NOT covered
Brand-name Chantix (varenicline tartrate)
Tobacco cessation products (OTC and Rx):
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| VACCINES (IMMUNIZATIONS) to prevent certain illnesses in people of all ages. Recommended doses, ages and populations may vary (Rx) | |
Children
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Adults
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FLUORIDE SUPPLEMENTS to help prevent cavities (dental caries) in children five years or younger whose water is low in fluoride.
All oral dosage forms up to 0.5 mg
Fluoride products (Rx):
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FOLIC ACID SUPPLEMENTS to help prevent birth defects in women who may become pregnant.
Generic dosage forms
Folic acid products (OTC):
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LIQUID IRON SUPPLEMENTS for children ages 6 to 12 months at risk for anemia.
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| BOWEL PREP MEDICINE for cleaning out the bowel before colonoscopy procedures for adults age 50 to 74. Colonoscopies screen for colon and rectal cancers. Generic preparations only UNLESS no generic is available. Brand name will no longer be supplied at no cost when the generic becomes available. |
STATINS to help prevent serious heart and blood vessel problems (cardiovascular disease) in adults age 40 to 75 who are at risk.
Generic low to moderate intensity statins (Rx):
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| Women’s Health Preventive Services | |
| Generic Oral Contraceptives/Transdermal Patches/Injectables, Barrier Contraception Methods (Diaphragms & Cervical Caps), Intrauterine Devices/Subdermal Rods/Vaginal Rings, Emergency Contraception (Rx or OTC), Vaginal Sponges and Spermicides are covered without cost share. Listings are subject to change and available by contacting Pharmacy Customer service line at 1-866-236-5936. Brand name will no longer be supplied at no cost when the generic becomes available. | |
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Prioritizing your health today to prevent issues tomorrow.
These trusted resources to take charge of your health and wellness. Click on the information you are interested in and choose a resource to learn more.
Call MedCom at 833-412-4144 and selection option 5 to be connected to a Quit Coach
Ready to quit? Take this quiz from the American Lung Association
