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Preventive Care

Category Service Who is Covered Frequency

Evaluation & Management
Preventive PCP Evaluation & Management Services (Adult) Members age 19 and older Every 1-2 years for adults 19-49 years of age. Every year for adults 50 years of age and older
Preventive PCP Evaluation & Management Services (Pediatric) Members age 0 - 19 Not Applicable
Preventive Ob-Gyn Evaluation & Management Services Female members Once per benefit period

Cancer-Related
Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing All members/Prior Authorization Required One-time genetic assessment
Breast Cancer Screening Female members Once per benefit period under age 40
Breast Cancer Preventive Medications Female members Not Applicable
Cervical Cancer Screening Female members Not Applicable
Colorectal Cancer Screening All members Once per benefit period
Prostate Cancer Screening Male members age 19 and older Once per benefit period

Counseling
Alcohol Behavioral Counseling Interventions, Adults All members Not Applicable
Diet Behavioral Counseling in Primary Care Members age 19 and older Not Applicable
Sexually Transmitted Infections, Counseling Adolescent and Adult members Not Applicable
Tobacco Use and Tobacco-Caused Disease, Counseling Members age 19 and older Not Applicable
Category Service Who is Covered Frequency

Immunizations
Pediatric Immunizations-Diphtheria/Tetanus/Pertussis, Haemophilus Influenzae Type b, Hepatitis A, Hepatitis B, Inactivated Poliovirus, Influenza, Meningococcal, Measles/Mumps/Rubella, Pneumococcal, Rotavirus, Varicella Members age 0 - 19 Not Applicable
Hepatitis A Immunization, Adult Members age 19 and older 2 doses
Hepatitis B Immunization, Adult Members age 19 and older 3 doses
HPV Immunization (Adults and Children) Members age 9 - 27 3 doses within six-month time frame
Influenza Immunization, Adult Members age 19 and older 1 dose annually
Measles, Mumps, Rubella and Varicella (Combination) Immunization, Adult Members age 19 and older 1 or 2 doses
Meningococcal Immunization, Adult Members age 19 and older 1 or more doses
Pneumococcal Immunization, Adult Members age 19 and older 1 or 2 doses
Tetanus, Diphtheria, Pertussis (Td/Tdap) Immunization, Adult Members age 19 and older Booster every 10 years
Varicella Immunization, Adult (Chicken Pox) Members age 19 and older 2 doses
Zoster (Shingles) Immunization Members age 60 and older 1 dose
Category Service Who is Covered Frequency

Screenings
Abdominal Aortic Aneurysm (AAA), Ultrasound Screening Male members age 65 - 75 Once per lifetime
Alcohol Misuse Screening, Adults All members Not Applicable
Autism Screening, Pediatric Members age 0 - 19 Not Applicable
Bone Mineral Density Screening All women 65 years and older or men 70 years and older Once every 2 years
Chlamydial Infection Screening All members All sexually active males and females, as recommended by your doctor
Congenital Hypothyroidism Screening Newborns Not Applicable
Dental Screening, Pediatric Members age 0 - 19 Not Applicable
Depression Screening (Adults) Members age 19 and older Not Applicable
Developmental Screening, Pediatric Members age 0 - 19 Not Applicable
Fasting Blood Glucose high-risk patients screenings should start at age 45 three-year intervals
Gonorrhea Screening All sexually active males and females As recommended by your doctor
Hearing Loss in Newborns, Screening Members age 0 - 19 Not Applicable
Hearing Screening, Pediatric Members age 0 - 19 Not Applicable
Hepatitis B Virus Infection Screening Female members Not Applicable
High Blood Pressure Screening Members age 19 and older Not Applicable
HIV Screening All sexually active males and females As recommended by your doctor
Iron Deficiency Anemia Screening Female members Not Applicable
Lipid Disorders in Adults, Screening Members age 20 and older every 5 years beginning at age 20
Major Depressive Disorder in Children and Adolescents, Screening Members age 12 - 18 Not Applicable
Obesity in Adults, Screening Members age 19 and older Not Applicable
Obesity in Children, Screening Members age 6 and older Not Applicable
Osteoporosis In Postmenopausal Women, Screening Female members age 65 and older Not Applicable
Phenylketonuria Screening Newborns Not Applicable
RH(D) Incompatibility Screening Female members Not Applicable
Sickle Cell Disease Screening Newborns Not Applicable
Syphilis Infection Screening All sexually active males and females As recommended by your doctor
Visual Impairment in Children Younger than Age 5, Screening Members age 0 - 5 Not Applicable
Vision Screening, Pediatric Members age 0 - 19 Not Applicable
Category Service Who is Covered Frequency

Other, Pediatric-Related
Alcohol and Drug Use Assessment, Pediatric Members age 0 - 19 Not Applicable
Dental Caries in Preschool Children, Prevention Members age 0 - 19 Not Applicable
Developmental Surveillance, Pediatric Members age 0 - 19 Not Applicable
Pediatric Measurements (Length/Height/Weight, Head Circumference, Weight for Length, Body Mass Index, Blood Pressure) Members age 0 - 19 Not Applicable
Psychosocial/Behavioral Assessment, Pediatric Members age 0 - 19 Not Applicable

Preventive Drug Measures
Aspirin Age limit ≥ 45 (men and women) Not Applicable
Iron Supplements Age limit = through year 1 Not Applicable
Oral Fluorides Age limit ≤ 6 yrs Not Applicable
Folic Acid Women, Age limit ≤ 55 Not Applicable
Tobacco Cessation Members age 19 and older Annual limit of 2 cycles of treatment (12 weeks per cycle)

Other
Breastfeeding, Behavioral Interventions to Promote Female members Not Applicable
Iron Deficiency Anemia, Preventions All members Not Applicable