2026 Update to Highmark’s Preventive Schedule and Preventive Health Guidelines

As part of this year’s update, Highmark is implementing new federal mandates from the Health Resources and Services Administration (HRSA), primarily impacting women's preventive health services, along with specific state-level updates for Delaware (DE), New York (NY), Pennsylvania (PA), and West Virginia (WV).

Vaccine Coverage 

Vaccines and vaccine coverage have been in the news recently. 

Highmark has not changed our vaccine coverage or medical policies on vaccinations. 

We remain committed to providing continued coverage for immunizations recommended in the 2025 Centers for Disease Control and Prevention (CDC) general vaccine schedule with members choosing what is best for them and their children in discussion with their health care provider. The American Academy of Pediatrics (AAP) immunization schedule follows the 2025 recommendations and can be used as a reference.  

Members should always consult with their physician about personal health care needs, including vaccines for themselves and their children.  

HRSA Updates 

1. Enhanced Breast Cancer Screening for Women Aged 40+ (Commercial Plans Only) for DE, NY, PA, and WV

• Expanded Coverage for Diagnosis: For women aged 40 and older, and younger with a doctor's advice, Highmark's commercial plans will now cover the full range of diagnostic services (mammogram, MRI, ultrasound, biopsy, and pathology evaluation) with no cost-sharing when there is no current diagnosis of breast cancer, but further investigation is needed to determine if cancer is present. 
• Purpose: This expansion aims to support definitive breast cancer diagnoses following an abnormal screening result. It applies to diagnostic tests that follow a screening work-up (e.g., after an abnormal screening mammogram) and are not related to other medical issues like breast implants. 
• Eligibility: This applies to eligible commercial and ACA members with the preventive schedule that includes women’s health preventive services. It does not apply to Medicaid or Medicare Advantage plans. 
• Important Nuances 
  • The benefit applies only when there is no current cancer diagnosis; its purpose is to diagnose new cancers. 
  • Certain employer groups may elect different preventive schedules, meaning not all members will have this added benefit. 
• DE, PA, and WV Only – Billing Reminder for Supplemental Breast Cancer Screening 
  • In January 2024 Provider News, we informed providers of the correct billing procedures for supplemental breast cancer screening for MRI and ultrasound:  
  • To point the claim to a no-cost share application, the diagnosis code Z1239 (other screening for breast cancer) needs to be billed with the procedure codes 76642, 76641, 77046, 77047, 77048, 77049.  
    • The medical reason is a secondary diagnosis. 

2. Patient Navigation Services for Breast and Cervical Cancer 

• Highmark is enhancing its Patient Navigation Services for breast and cervical cancer, which will be available with no cost-sharing. 
• Purpose: These services (including Well 360 and Customer Service assistance) will help guide women to appropriate services and resources, improving utilization of screening and follow-up care. 

3. Clarified Language for Domestic and Intimate Partner Violence Screening 

• The existing women's health preventive schedule now includes updated language for Intimate Partner and Domestic Violence Screening and Counseling for adolescent and adult women. 
• Key Point: This screening and referral to intervention services is integral to the exam and is not separately billable, and it remains part of the women's health preventive schedule. 

State-Specific Updates 

• Delaware Only – Prostate Cancer Screening 
  • Clarification of existing Delaware state law confirms coverage for PSA tests and Digital Rectal Exams (DRE) for prostate cancer screening. 
  • This applies to men aged 50+ (general population) and 40+ (high-risk) once annually. 
  • Catastrophic (CAT) Plans: For CAT plans, members must meet their deductible first, as this is a state, not federal, mandate. 
• Pennsylvania Only – COVID Vaccine 
  • Language regarding COVID vaccine eligibility has been updated to be more flexible: “Per doctor’s advice” (removing specific CDC and Emergency Use Authorization guidelines). 
• Pennsylvania and West Virginia – PSA Test Not on Preventive Schedule 
  • For PA and WV, PSA tests for asymptomatic purposes are not part of the standard preventive schedule. 
  • Important Provider Advisory: Providers should inform patients in PA and WV that they may incur out-of-pocket costs for PSA screening tests to avoid member abrasion and surprise billing, as there is no state mandate for these tests to be covered preventively. 

Download the Guidelines 

To help make the information more accessible and convenient for you, the complete set of 2026 Preventive Health Guidelines is posted here on the Provider Resource Center.  Go to Resources and Education in the main menu and look under Clinical Quality and Education.

To obtain a written copy of the guidelines, email Clinical Quality at ClinicalQualityOutreach@highmark.com.