Preventive Care: What’s Covered in Washington

After you've been diagnosed with a medical condition, tests to monitor that condition are no longer considered preventive, and will be billed as diagnostic. Your doctor might also order tests that are not covered as preventive. That means services are subject to cost shares like copays, coinsurance, and deductible.

We cover mammograms for men and women, subject to the terms of specific plans, based on what you and your healthcare provider decide is best for you, including your risks and preferences. Computer-aided and 3Dmammography are also covered. If done as a diagnostic test rather than preventive screening, it may be subject to cost shares like copays, coinsurance, and deductible.

Preventive screenings vary for men and women. Your health plan covers preventive care services as required by state and federal law. For more information, review the "A" and "B" rated services on the United States Preventive Task Force, immunizations recommended by the Centers for Disease Control and Prevention, and preventive care and screening recommended by the Health Resources and Services Administration. See the list on healthcare.gov.

Colonoscopies are tests used to detect colon cancer and are covered as part of preventive checkups from age 45-75. Your plan covers repeat screenings every 5 years. While colonoscopies certainly aren't pleasant, they can be life-saving. If you have a strong family history of colon cancer, you may be covered for colonoscopy at an earlier age.

A colonoscopy examines the entire colon. The test includes a consultation prior to your screening and preparation, and gentle sedation is often used (although some people may need anesthesia). Your initial screening colonoscopy is covered in full on many plans, even if polyps are found (whether benign or cancerous). Follow-up colonoscopies for those who have had a cancerous polyp are not considered screening and are subject to a copay and your deductible.

Note: This procedure can cost more than $2,000. Be sure you know the date of your last screening before you schedule your 5-year follow-up. Your online claims are accessible via your secure LifeWise account for only 3 years. If you're unsure when your last screening was done, contact your doctor’s office. To check your coverage, contact us.

Anesthesia
Full anesthesia isn't always covered as part of your colonoscopy. Your doctor will determine what level of anesthesia is right for you to ensure you're as comfortable as possible.

A request for "extra" or full anesthesia won't necessarily be covered, and you'll be responsible for this expense.

Preparing for your test
Colonoscopies include over-the-counter, pre-colonoscopy laxatives, also called cleansing preparations. Your plan coverage is limited to 2 preparations every 365 days, and they require a written prescription from your doctor.

At-home screening options have made colon cancer screenings much simpler. However, they're not appropriate for everyone. Talk to your doctor. Depending on your family history and risk factors, they might recommend one over another.

A fecal occult blood test (FIT) test is simple. These tests can be an alternative to a colonoscopy, assuming you don't have other risk factors. They're done at home without special preparation, in the comfort of your own bathroom. There are two types of test kits on the market for at-home colon cancer screening are Cologuard (DNA FIT) and standard FIT kits.

Are there accurate and cost-effective at-home colon cancer screening tests?
Yes. FIT and FOBT tests are accurate and cost-effective at-home screening options. The fecal occult blood test (FOBT) and fecal immunochemical test (FIT) are both recommended by the U.S. Preventive Services Task Force for at-home colon cancer screenings. Although these tests are recommended annually, the total cost of annual FIT/FOBT tests remains less expensive (about $30.00 which is typically fully covered for members when prescribed as part of a preventive screening) than a single Cologuard test every 3 years. We encourage you to discuss this option with your provider.

Is  Cologuard more accurate than a traditional FIT kit?
No. Cologuard includes a patented DNA test unique on the market. However, Cologuard often results in false positives for abnormal DNA markers that aren’t explained by subsequent colonoscopy findings. False positives that aren’t explained by colonoscopy findings may generate unnecessary ongoing surveillance or anxiety for patients. The Cologuard test is also a more expensive test because of the DNA testing. LifeWise pays for a large cost share of the Cologuard test, however Exact Sciences Laboratories, the only company that offers the Cologuard test, balance bills members about $200, depending on the your health plan.