Preventive Services Exempt from Cost Share (includes Health Care Reform) - Commercial

Transcription

1 Preventive Services Exempt from Cost Share (includes Health Care Reform) - Commercial Important Notes STOP! Are you using the correct grid? Municipalities Sections Every effort will be made to keep this document current based on FDA approvals. Configuration might not have been able to be completed at the time this publication is updated. The preventive services in this document are exempt at the in-network level only. This is not a benefit limitation grid. Refer to plan documents for benefit information. This grid may not be applicable to self-funded groups or municipalities that have customized benefits. Be sure to check plan documents and any related custom benefits job aids. For additional questions about this document, see your Supervisor. Supervisors should contact Code Management Group (CMG) for assistance if necessary. ICD10 codes become effective for dates of service 10/1/15 and beyond. Use this grid for Groups whose benefit summary contains a "Prevention & Wellness" section (applies with no regard to whether or not the plan is Grandfathered) Refer to the Preventive Services Exempt from Deductible grid (does not include Health Care Reform) - Commercial grid for groups who are Grandfathered and their benefit summary does not contain a "Prevention & Wellness" section. Some municipalities have variations from the standard cost share exemption guidelines. Such municipalities are identified as follows: MUNIPLTY rider is applied to the division and appears on the AMISYS Rider Profile Inquiry Screen (IQ2100 ) MUNIPLTY rider is noted on this grid to indicate differences from the standard Click on the appropriate link to view the list of preventive services. General Preventive Screenings and Counseling Specific Screenings Immunizations Pharmacy General Preventive Screenings and Counseling Preventive Service Procedure Code ICD-9 / ICD10 Pairing Exempt From Guidelines Location/Comment Preventive screenings 99384, 99385, 99386, None For Men: 03, 11, 19, 22, 50, and counseling 99387, 99394, 99395, Frequency: Cost share waived on 71, 72 pamspina Page 1 04/12/11

2 99396, use of one code/member/yr Frequency MUNIPLTY: Refer to plan documents 993, 99382, 99383, 99391, 99392, For Women: Members in plans that have not yet renewed Frequency: Cost share waived on use of one code/member/yr Frequency MUNIPLTY: Refer to plan documents Members in plans that are new or renew on or after 8/1/12** None 96160, None For Men: For Women: Members in plans that have not yet renewed 03, 11, 19, 22, 50, 71, 72 03, 11, 19, 22, 50, 71, 72 03, 11, 19, 22, 50, 71, 72 03, 11, 19, 22, 50, 71, 72 Members in plans that are new or renew on or after 8/1/12** 99401, 99402, 99403, None For Men: 03, 11, 19, 22, 50, pamspina Page 2 04/12/11

3 99404 Frequency: Cost share waived on use of one code/member/yr For Women: Members in plans that have not yet renewed Frequency: Cost share waived on use of one code/member /yr 71, 72 03, 11, 19, 22, 50, 71, 72 Members in plans that are new or renew on or after 8/1/12** Preventive Service Procedure Code ICD-9 / ICD10 Pairing Abdominal Aortic Aneurysm (AAA) screening ICD9 - V15.82 ICD10 - Z Alcohol screening 99408, 99409, G0396, ICD9 - V79.1 G0397, G0442, G0443 ICD10 Z13.89 Assay, Thyroid* (effective 7/1/16) icd9 V20.0, V20.1, V20.2, V20.3, V20.31, V20.32, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 ICD10 Specific Screenings Exempt From Guidelines Frequency: 1x/lifetime Age Band: years Comment Location: 11, 19, 22, 50, 71, 72 03, 11, 19, 22, 50, 71, 72 Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not pamspina Page 3 04/12/11

4 Assay, Vitamin D* Autism, psychosocial/behavioral and developmental screening Blood count* 85004, 85007, 85008, 85014, 85018, 85025, Breast cancer, counseling for genetic testing Breast cancer, genetic testing (BRCA) Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z ICD10 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z , None Age Band: 0 21 years V13.3, V70, V70.0, V70.8, V70.9, V20.2, V72.3, V72.31 Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z00.121, Z00.129, Z01.411, Z V10.3, V10.43, V16.3, V16.41 Z85.3, Z85.43, Z80.3, Z , 212, 213, 214, 215, 216, 217 All Others: Deductible only MUNIPLTY: Frequency: 1 x/year None Frequency: N/A exempt. 11, 19, 22, 50,71, 72, Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not exempt. 11,19, 22, 50, 71, 72, PCP only 11, 19, 22, 50, 71, 72 11, 19, 22, 17, 50, 71, 72, 11,19, 22, 50, 71, 72 19, 22, pamspina Page 4 04/12/11

5 Breast feeding support 99501, None Members in plans that have not yet renewed Frequency: one per 10 rolling months 99501, 97802, V24.1 Members in plans that are new or renew on or after 8/1/12** Z39.1 Frequency: 8x/year Breast pumps E0602 Effective 7/1/15: E0603 Effective 5/1/17: E0604 Breast pump supplies A42, A4282, A4283, A4284, A4285, A4286 Breast tomosynthesis screening* (CT Large group only effective 1/1/2017 for new & renewing) Z12.31, Z12.39, Chlamydia screening 86631, 86632, 87110, 87140, 87270, 87320, 87490, 87491, 87492, 87800, 87801, 870 None This service applies to members in plans that are new or renew on or after 8/1/12. ** Frequency: one per 10 rolling months None This service applies to members in plans that are new or renew on or after 8/1/12. ** V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9, V73.88, V73.98 Z34.00 Z34.03, Z All costshare Age Band: 40+ years 11, 12, 19, 22, 50, 71, 72 11, 12,19, 22, 50, 71, E0604 requires prior authorization , 19, 22, 50, 71, 72 pamspina Page 5 04/12/11

6 Colonoscopy, Pre- Procedure Screening with a Gastroenterologist (effective 1/1/2016) 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.291, O09.40-O09.43, O O09.213, O09.219, O O09.293, O09.299, O09.30-O09.33, O O09.513, O09.519, O O09.523, O09.529, O O09.613, O09.619, O O09.623, O09.629, O09.1- O09.3, O09.9, O O09.823, O09.829, O09.70-O09.73, O O09.893, O09.899, O09.90-O09.93, Z11.8 Z01.8 Age Band: years 11, 19, 22, 50, 71, 72 For additional information, please review the Colonoscopy Job Aid Colon cancer screening (Ancillary services) For additional information, please review the Colonoscopy Job Aid 000, 88305, 0270, 0271, 0272, 0370, , 211.4, 211.9, 455.0, , , 569.0, 569.3, 578.1, 578.9, V10.05, V10.06, V12.70, V12.72, V12.79, V16.0, V18.5, V18.51, V18.59, V76.41, V76.50, V76.51 D D12.6, K63.5, D12.7 D12.9, D13.9, Age Band: years 11, 19, 22, 24, 50, 71, 72 pamspina Page 6 04/12/11

7 Colon cancer screening (procedures) For additional information, please review the Colonoscopy Job Aid Colon cancer screening (lab test stool for occult blood) Contraceptive counseling Contraceptive counseling and 44388, 44389, 44391, 44392, 44394, 44401, 45300, 45303, 45305, 45308, 45309, 45315, 45317, 45320, 45330, 45331, 45338, 45346, 45378, 45380, 453, 45382, 45384, 45385, 45388,74263, G0104, G0105, G0106, G0121, G0328 K64.0, K64.1-K64.3, K64.8, K57.30, K57.50, K57.90, K57.20, K57.32, K57.40, K57.52, K57.80, K57.92, K62.0, K62.1, K62.5, K92.1, K92.2, Z85.038, Z85.048, V87.19, Z86.010, Z87.19, Z80.0, Z83.71, Z83.79, Z12.12, Z12.10, Z12.11 None Age Band: years 82270, None Age Band: years 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99201, 99202, 99203, 99204, 99205, 99211, V25.01, V25.02, V25.04, V25.09, V25.11, V25.12, V25.13, V25.2, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.9 Z30.011, Z30.013, Z30.014, Z30.018, Z30.02, Z30.09, Z30.430, Z30.432, Z30.433, Z30.2, Z30.40, Z30.41, Z30.431, Z30.42, Z30.49,Z30.019, Z30.49, This service applies to members in plans that are new or renew on or after 8/1/12. ** V25.03 This service applies to members in plans that are new 11, 19, 22, 24, 50, 71, 72 03, 11, 19, 22, 50, 71, 72 03, 11, 19, 22, 23, 50, 71, 72 pamspina Page 7 04/12/11

8 treatment (Emergency) 99212, 99213, 99214, 99215, 992, 99282, 99283, 99284, 99285, 0450 Contraceptive methods A4266 Effective 8/1/13 J1050, J7300, J7301, J7307 Effective 1/1/16 J7297, J7298 Effective 5/1/17 J7304, J7306 Z or renew on or after 8/1/12. ** None This service applies to members in plans that are new or renew on or after 8/1/12. ** 03, 11,19, 22, 23, 24, 50, 71, 72 Note: J7301 was effective 1/1/14 Contraceptive methods (Ancillary services) Effective 7/1/17 Q V25.09, V25.49, V25.9 Z30.09, Z30.42, Z30.49, Z , 11980, 119, 11982, V25.43, V25.5 Z30.49, Z30.019, Z , 58301, , V25.11, V25.12, V25.13, V25.42 T83.6XXA, Z30.430, Z30.432, Z30.433, Z , 88302, 88305, 0250, 0258, 0270, 0271, 0272, 0278, 0279, 0370, 0710, , V25.11, V25.12, V25.13, V25.42,V25.43, V25.5 This service applies to members in plans that are new or renew on or after 8/1/12. ** This service applies to members in plans that are new or renew on or after 8/1/12. ** This service applies to members in plans that are new or renew on or after 8/1/12. ** This service applies to members in plans that are new or renew on or after 8/1/12. ** Location: 03, 11,19, 22, 23, 24, 50, 71, 72 03, 11, 19, 22, 23, 24, 50, 71, 72 03, 11, 19, 22, 23, 24, 50, 71, 72 03, 11,19, 22, 23, 24, 50, 71, 72 pamspina Page 8 04/12/11

9 Effective 5/1/17 T83.6XXA, Z30.430, Z30.432, Z30.433, S49, S4989 Z30.431, Z30.49, Z Creatinine* None All Others: Deductible only Dental Caries Prevention (effective 1/1/2015) Note: This is a change from original config Depression screening G0444 V79.0 Diabetes screening 82947, 82948, 82950, 82962, Diabetes screening, gestational 82947, 82950, 82951, 82962, MUNIPLTY: None Age Band: 0 5 years Z13.89 V77.1 Z , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O O09.33, O O09.513, O09.519, O O09.523, O09.529, OO Age Band: 12 years and over This service applies to members in plans that are new or renew on or after 8/1/12. ** Frequency: 2x/year Location: 11, 19, 22, 50, 71, 72 PCP only 03, 11, 19, 22, 50, 71, 72 11, 19, 22, 50, 71, 72, pamspina Page 9 04/12/11

10 Dietary counseling (Individuals with hyperlipidemia, cardiovascular risk factors) 97802, 97803, 97804, G0446, S9470, 0942 O O09.619, O O09.623, O09.629, O09.899, O O09.823, O09.829, O09.70-O09.73, O09.1-O09.3, O09.9, O O09.893,O09.899, O O09.93 V15.82, V17.3, V17.49, V65.3, V77.8, V77.91 Z87.891, Z82.49, Z71.3, Z13.89, Z EKG* 93000, 93005, None Executive Profile* V20.0, V20.1, V20.2, V20.3, V20.31, V20.32, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z General Health Panel* V20.0, V20.1, V20.2, 11, 19, 22, 50, 71, 72 11, 19, 22, 50, 71, 72 Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not exempt. Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not exempt. pamspina Page 10 04/12/11

11 Gonorrhea screening 87590, 87591, 87592, Gynecological exam 99384, 99385, 99386, 99387, 99394, 99395, 99396, Hearing screening 92551, 92552, 92553, 92558, 92568, 92585, 92586, 0470, 0471, 0479 Hematocrit/Hemoglobin screening in children/adolescents (non-hcr refer to Blood Count*) Hepatitis B Screening (effective 1/1/15) V20.3, V20.31, V20.32, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z None Members in plans that have not yet renewed V72.3, V72.31 Z01.411, Z Members in plans that are new or renew on or after 8/1/12** None V20.2, V70.0 Z00.121, Z00.129, Z00.00, Z00.01 Members in plans that have not yet renewed when provided by OB/Gyn or PCP when provided by OB/Gyn or PCP Members in plans that are new or renew on or after 8/1/12** Frequency MUNIPLTY: Refer to plan documents Age Band: 0 21 years 85014, None Age Band: 0 21 years 87340, None Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not exempt. 03, 11,19, 22, 50, 71, 72 Any PCP only 03, 11,19, 22, 50, 71, 72 PCP only Location: 11,19, 22, 50, 71, 72, pamspina Page 11 04/12/11

12 Hepatitis C Screening (effective 6/1/14) HIV testing 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87539, 87806, G0432, G0433, G0435, S3645 Human Papilloma Virus (HPV) screening 86803, None None 87623, 87624, Members in plans that have not yet renewed: V20.2, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z00.121, Z00.129, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z Members in plans that are new or renew on or after 8/1/12** None Members in plans that have not yet renewed: Exempt from deductible only Members in plans that are new or renew on or after 8/1/12** Exempt from all cost share Members in plans that have not yet renewed: Members in plans that are new or renew on or after 8/1/12** Age Band: 30 years and over Lead screening None Age Band: 0-6 years Lead screening* V20.2, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z00.121, Z00.129, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, All Others: Deductible only MUNIPLTY: Location: 11, 19, 22, 50, 71, 72, For HIV counseling refer to Preventing screenings and counseling 11, 19,22, 50, 71, 72, PCP only pamspina Page 12 04/12/11

13 Lipid screening 80061, 82465, 83718, 83719, 83721, 84478, Lipid screening* 80061, 82465, 83718, 83721, 84478, Z V77.91 Z V20.2, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z00.121, Z00.129, Z00.00, Z00.01, Z00.5, Z00.70, All Others: Deductible only MUNIPLTY: 11, 19, 22, 50, Z00.71, Z00.8, Z01.411, Z MUNIPLTY: also includes: V20.0, V20.1, V20.3, V20.31 & V20.32 Lung Cancer Screening (effective 6/1/2014) Mammography 77067, G0202, 0401, 0403 Z76.1, Z76.2, Z00.110, Z , V15.82, V76.0 MUNIPLTY: also includes: 77065, 77066, G0204, G0206 F17.200, F17.201, F17.210, F17.211, F17.290, F17.291, Z87.891, Z12.2 V76.10, V76.11, V76.12, V76.19 Z12.31, Z12.39, Age Band: years Age Band: 40+ years Location: 11, 19, 22, 50, 71, 72 11, 19, 22, 50, 71, 72 Mammography (Baseline) * 77067, G0202 None Refer to frequency/age guidelines Frequency: CMI members can get ONE baseline mammogram between 11, 19, 22, 50, 71, 72 pamspina Page 13 04/12/11

14 Maternity, antepartum/prenatal care MUNIPLTY: also includes: 77065, 77066, G0204, G0206 age exempt from deductible. CCI members ages can get baseline but it is subject to cost share and not exempt from the deductible MUNIPLTY members: Unlimited and exempt from all cost share Age Band: years 59425, None Members in plans that are new or renew on or after 8/1/12** Frequency: N/A Maternity, initial visit V V22.2, V V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23. - V23.86, V23.87, V23.89, V23.9, V72.42, V V91.03, V91.09, V V91.12, V V91.22, V91.29, V V91.92, V91.99 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O O09.33, O O09.513, O09.519, O O09.523, O09.529, OO O O09.619, O O09.623, O09.629, O09.899, Members in plans that are new or renew on or after 8/1/12** Frequency: N/A 11, 19, 22, 50, 71, 72 11, 19, 22, 50, 71, 72 pamspina Page 14 04/12/11

15 Medical Nutrition Therapy (Tele-Health) Newborn screening, hypothyroidism G0270 O O09.823, O09.829, O09.70-O09.73, O09.1-O09.3, O09.9, O O09.893,O09.899, O O09.93, Z32.01, O O30.003,O30.009, O O30.033, O30.039,O O30.043, O30.049, O O30.093,O30.099, O O30.103,O30.109, O O3.113, O30.119, O O30.123, O30.129, O O30.193, O30.199, O O30.203, O30.209, O O30.213, O30.219, O30.223, O30.229, O O30.293, O30.299, O O30.803, O30.809, O30.1- O30.3, O30.9, O O30.823, O30.829, O O30.893, O E66.09, E66.1, E66.8, E66.9, E66.01, Z71.3, Z13.89, Z87.891, Z82.49, All Cost Share For Tele-Health Network Frequency: 2x/year Z71.3, Z13.89, Z13.220, 84437, None Age Band: days 11 pamspina Page 15 04/12/11

16 Newborn screening, PKU Newborn screening, sickle cell disease Obesity screening and Interventions None Age Band: days None Age Band: days 97802, 97803, 97804, 0942, G0447, S9470 Osteoporosis screening 76977, 77078, 77080, 770, 77085, G0130 Pap smear 841, 842, 843, 847, 848, 850, 852, 853, 854, 855, 864, 865, 866, 867, 874, 875 Assessment for Fall Prevention Pregnancy, bacteriuria screening See Preventive Screening and Counseling , , V65.3, V77.8 E66.09, E66.1, E66.8, E66.9, E66.01, Z71.3, Z13.89 V17., V82. Z Frequency: 4x/year Frequency: Every 23 months Age Band: 60+ years None 87086, , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V , 22, 50, 71, 72, 19, 22, 50, 71, 72, 11, 19, 22, 50, 71, 72 11, 19, 22, 50, 71, 72 pamspina Page 16 04/12/11

17 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O O09.33, O O09.513, O09.519, O O09.523, O09.529, OO O O09.619, O O09.623, O09.629, O09.899, O O09.823, O09.829, O09.70-O09.73, O09.1-O09.3, O09.9, O O09.893,O09.899, O O09.93 Pregnancy, blood count 85025, , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O pamspina Page 17 04/12/11

18 Pregnancy, Hepatitis B screening O09.33, O O09.513, O09.519, O O09.523, O09.529, OO O O09.619, O O09.623, O09.629, O09.899, O O09.823, O09.829, O09.70-O09.73, O09.1-O09.3, O09.9, O O09.893,O09.899, O O , , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O O09.33, O O09.513, O09.519, O O09.523, O09.529, OO O O09.619, O O09.623, O09.629, O09.899, O O09.823, O09.829, O09.70-O09.73, pamspina Page 18 04/12/11

19 Pregnancy, Rh (D) typing Pregnancy screening panel includes HepB, blood count, Rh (D), syphilis, HIV O09.1-O09.3, O09.9, O O09.893,O09.899, O O , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23., V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9 Z34.00 Z34.03, Z Z34.83, Z34.90-Z34.93, Z33.1, O09.00-O09.03, O09.10-O09.13, O O09.43, O O09.213, O09.219, O O09293, O09.299, O O09.33, O O09.513, O09.519, O O09.523, O09.529, OO O O09.619, O O09.623, O09.629, O09.899, O O09.823, O09.829, O09.70-O09.73, O09.1-O09.3, O09.9, O O09.893,O09.899, O O , 800 None 11, 19, 22, 50, 71, 72, pamspina Page 19 04/12/11

20 Prostate Cancer Screening* Sexually transmitted infections, counseling (coverage expanded to include males effective 7/1/15) Smoking cessation (individual & group counseling) Smoking cessation (telephone counseling) 84152, 84153, V20.0, V20.1, V20.2, V20.3, V20.31, V20.32, V70, V70.0, V70.8, V70.9 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8 G0445 None This service applies to members in plans that are new or renew on or after 8/1/12. ** Frequency: 2x/year Age Band: 12 years and over 99406, V15.82, 305.1, , 98967, Sterilization 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264 Sterilization (Ancillary services) 00851, 88302, 88305,0250, 0258, 0270, 0271, 0272, 0278, 0279, 0370, 0710 Syphilis screening 86592, 86593, 86780, 87164, 87166, Z87.891, F17.200, F17.201, F17.210, F17.211, F17.290, F17.291, Frequency: 8x/year None This service applies to members in plans that are new or renew on or after 8/1/12. ** Frequency: N/A V25.03, V25.2, V26.51 Z30.012, Z30.2, Z98.51 This service applies to members in plans that are new or renew on or after 8/1/12. ** Frequency: N/A None Important: Cost share & guidelines for this service apply to members with MUNIPLTY rider only. For all other members this service is not exempt. 03, 11, 19, 22, 50, 71, 72 Location: 03, 11, 19, 22, 50, 71, 72 11, 19, 21, 22, 24 11, 19, 21, 22, 24, 50, 71, 72, 11, 19, 22, 50, 71, 72 pamspina Page 20 04/12/11

21 TB testing None Age Band: 0-21 years TB testing* None All Others: Deductible only MUNIPLTY: 11, 19, 22, 50, 71, 72 PCP only 11, 19, 22, 50, 71, 72 Latent Tuberculosis Screening (LTBI) 86480, (effective 10/1/2017) Urinalysis* 000, 001, 002, 003, 005 Z00.121, Z00.129, Z11.1. Z20.1 V70, V70.0, V70.8, V70.9, V20.2, V72.3, V72.31 Z00.121, Z00.129, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z Venipuncture* 36415, V20.2, V70, V70.0, V70.8, V70.9, V72.3 & V72.31 Z00.121, Z00.129, Z00.00, Z00.01, Z00.5, Z00.70, All Others: Deductible only MUNIPLTY: All Others: Deductible only MUNIPLTY: 11,19,22,50,71,72, Z00.71, Z00.8, Z01.411, Z MUNIPLTY: also includes: V20.0, V20.1, V20.3, V20.31 & V20.32 Z76.1, Z76.2, pamspina Page 21 04/12/11

22 Vision screening in all ages* Vision screening in children Z00.110, Z , 92004, 92012, 92014, 92015, 92018, , 367.8, 92019, , 367.9, V72.0, V53.1, V , H52.00-H52.03, H H52.13,H H52.203, H52.209, H H52.223, H52.229, H H52.213, H52.219, H52.31, H52.32, H52.4, H52.7, Z01.00, Z01.01, Z00.121, Z , V20.2 Z00.121, Z All Others: Deductible only MUNIPLTY: Age Band: 0-21 years 11, 19, 22, 50, 71, 72 Optometrist or Ophthalmologist only 11, 19, 22, 50, 71, 72 PCP only Immunizations Refer providers to CDC website for guidelines: CDC Child, Adolescent & Catch-up Immunization Schedules CDC Adult Immunization Schedule Locations: All Preventive Service Procedure Code ICD-9 / ICD10 Exempt From Guidelines Pairing Immunization 90460, 90461, 90471, None Provider must adhere to FDA/CDC age/frequency/gender guideline. administration 90472, 90473, Diptheria None Provider must adhere to FDA/CDC age/frequency/gender guideline. Diptheria, tetanus, None Provider must adhere to FDA/CDC age/frequency/gender guideline. acellular pertussis (DTaP) Diptheria, tetanus None Provider must adhere to FDA/CDC age/frequency/gender guideline. (Td) Diptheria, tetanus, None Provider must adhere to FDA/CDC age/frequency/gender guideline. pamspina Page 22 04/12/11

23 acellular pertussis (Tdap), age 7 or older Diptheria, tetanus, None Provider must adhere to FDA/CDC age/frequency/gender guideline. acellular pertussis, Hepatitis B, polio (DtaP-HepB-IPV) Diptheria, tetanus, None Provider must adhere to FDA/CDC age/frequency/gender guideline. acellular pertussis, HIB (DTaP-HIB) Diptheria, tetanus, None Provider must adhere to FDA/CDC age/frequency/gender guideline. acellular pertussis, HIB, polio (DTaP- HIB-IPV) Diptheria preservative None Provider must adhere to FDA/CDC age/frequency/gender guideline. free, tetanus (Td), age 7 or older DTAP-IPV None Provider must adhere to FDA/CDC age/frequency/gender guideline. Hepatitis A 90632, 90633, None Provider must adhere to FDA/CDC age/frequency/gender guideline. Hepatitis A/Hepatitis None Provider must adhere to FDA/CDC age/frequency/gender guideline. B Combo Hepatitis B 90739, 90740, 90743, None Provider must adhere to FDA/CDC age/frequency/gender guideline , 90746, Hepatitis B/HIB None Provider must adhere to FDA/CDC age/frequency/gender guideline. Combo Herpes Zoster Vaccine HIB (Hemophilus influenza b) HPV (Human Papillomavirus) Vaccine None Age Band: 50+ years 90647, None Provider must adhere to FDA/CDC age/frequency/gender guideline None Age Band: 9-26 years None Age Band: 9-26 years None Age Band: 9-26 years pamspina Page 23 04/12/11

24 Influenza (flu) Vaccine 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90661, 90682, 90685, 90686, 90687, 90688, 90673, None Provider must adhere to FDA/CDC age/frequency/gender guideline. Measles Immunization Measles-Mumps- Rubella (MMR) Virus Immunization Measles-Mumps- Rubella-Varcella (MMRV) Measles-Rubella Immunization Meningitis Vaccine (Fluzone High Dose) None Age Band: 65+ years None Provider must adhere to FDA/CDC age/frequency/gender guideline None Provider must adhere to FDA/CDC age/frequency/gender guideline None Provider must adhere to FDA/CDC age/frequency/gender guideline None Provider must adhere to FDA/CDC age/frequency/gender guideline (effective 1/23/15),90621 (effective 2/1/15), 90733, None Provider must adhere to FDA/CDC age/frequency/gender guideline None Provider must adhere to FDA/CDC age/frequency/gender guideline. Meningitis-HIB Vaccine Pneumococcal None Provider must adhere to FDA/CDC age/frequency/gender guideline. Vaccine, 13 valent Pneumococcal 90732, None Provider must adhere to FDA/CDC age/frequency/gender guideline. Vaccine Over age 2 and adult Poliomyelitis, None Provider must adhere to FDA/CDC age/frequency/gender guideline. inactivated (IPV) Immunization Poliovirus, oral (OPV) None Provider must adhere to FDA/CDC age/frequency/gender guideline. Immunization Rotavirus Vaccine 90680, 906 None Provider must adhere to FDA/CDC age/frequency/gender guideline. Rubella Immunization None Provider must adhere to FDA/CDC age/frequency/gender guideline. Varicella None Provider must adhere to FDA/CDC age/frequency/gender guideline. pamspina Page 24 04/12/11

25 Preventive Service Aspirin Prevention Bowel preparation agents Breast Cancer Primary Prevention (effective 7/1/14) Cholesterol/Statin Prevention (effective 11/1/17) Contraceptives Folic acid supplements for women of childbearing age Oral fluoride supplements for children Smoking Cessation Vitamin D supplements for fall prevention Pharmacy Refer providers to CDC website for guidelines: CDC Child, Adolescent & Catch-up Immunization Schedules CDC Adult Immunization Schedule Description Coverage of over-the-counter generic aspirin (< 325mg) when prescribed by a physician Members <60 years of age Coverage of generic prescription and certain generic OTC preparation agents for colonoscopy screenings with no cost share when prescribed by a physician For members years Limited to 2 per year Coverage of tamoxifen and raloxifene for the purpose of primary prevention of invasive breast cancer for women at high risk, who do not have a prior history of a diagnosis of breast cancer. The process for coverage at $0 requires prior authorization from the prescribing physician. Women > 35 years of age Coverage of select generic strengths of low to moderate dose statins to prevent cardiovascular disease for individuals at high risk with one or more cardiovascular risk factors, such as dyslipidemia, diabetes, hypertension, or smoking. For Members years of age This service applies to members in plans that are new or renew on or after 8/1/12. ** See ConnectiCare s Drug Lists for more information. Diaphragms Mirena, Kyleena (intrauterine device) Generic oral contraceptives Generic emergency contraceptives Coverage of generic folic acid supplements (0.4mg through 0.8mg strengths only) with no cost share when prescribed by a physician For females through 50 years of age Coverage of generic oral dosage forms of fluoride supplements (< 0.5mg/day) with no cost share when prescribed by a physician For children between 0 and 5 years of age Coverage of all FDA-approved prescription and OTC tobacco cessation products with no cost share when prescribed by a physician For members 18 and older. Coverage of oral generic prescription and generic OTC single entity vitamin D2, D3 products and combination products that also contain calcium, with vitamin D doses of < 1,000 IU per dosage form with no cost share when prescribed by a physician For members 65 and older pamspina Page 25 04/12/11

26 Footnotes: * Not part of Health Care Reform. ** Part of Women s Health Care Mandate, effective 8/1/12. Revision Record Date Reason for Revision 09/16/10 Original document developed. 10/07/10 Lead screening - revised age from All to 0-6; Iron Deficiency - changed to "Blood Count"; Vision screening - revised Procedure codes, ICD-9 codes, and age band. 12/14/10 Changed Age Bands with "none" to "All"; clarified some Comments 01/26/11 Added Creatinine 82565; revised the overview regarding what grid to use. 02/15/11 Added note that grid may not apply to SF groups with custom benefits; added code (Immunizations); added V70.9 (Venipuncture) 03/03/11 Added V70.9 to Urinalysis 03/07/11 Added Important Notes section 03/22/11 Corrected Smoking Cessation (added C & G codes) and Immunizations (added Q codes) 03/24/11 Removed bullet referring to V202 and V700 under important note. Removed what is date of service question under Are you using the correct grid section. 04/12/11 Added and under Immunizations. 05/25/11 Updates per CMG review 06/24/11 Removed G0394 from Colon Cancer Screening b/c code is obsolete. 09/16/11 TB Testing for PCP Only Changed age band from all to /23/11 Added note to refer users to their Supervisors with questions about this doc. Supervisors should contact CMG if necessary. 11/09/11 Revised age band for to age /10/11 Codes 90649, (HPV vaccine, immunization section) revised age/gender restrictions. 11/29/11 Added to Immunizations section. 02/20/12 Added new row for Lipid Screening* exempt from deductible only (V70, V700, V708, V709, V202, V723 & V7231). pamspina Page 26 04/12/11

27 08/01/12 Updated guidelines throughout doc for mbrs in groups that renew on/after 8/1/12. Alcohol added G0396, G0397, G0442, G0443. Blood cnt (85025, 85027) renamed as pregnancy blood cnt; added Breast feed support - added 97802, 97803, v24.1 Colon cancer screen proced added 45330, 45333, 45334; deleted 0270, 0271, 0272, 0370, 0710, 000, 88305; deleted all ICD pairings. Diabetes screen deleted Dietary counseling added G0446; deleted pairing ; added V15.82, V17.3, V17.49, V65.3, V77.8, V Gonorrhea screen deleted 870, 87205, 87800, Gyn exam removed asterisk(*); updtd frequency for plans that are new/ renew on/after 8/1/12. Hearing screen added 92558; deleted 92566, 92587, HIV test added 87391, 87537, 87538, 87539, G0432, G0433, G0435; deleted 870. HPV screen - removed asterisk(*) Lipid screen (HCR) added Newborn screen sickle cell deleted 87143; added Obesity screening - added G0447, , , V65.3, V77.8; deleted V8535, V8536, V8537, V8538, V8539, V854. Osteoporosis screen deleted G0134; added G0130. Pregnancy screen, bacteriuria added Pregnancy screen, Hep B added Syphilis screen added 86780; deleted 867; added male gender guideline. Vision screen child added V20.2; deleted V202, V70, V700, V708, V709 Immunizations added 90474, 90743, 90746, 90645, 90646, 90647, 90648, 90660, 90662, 90644; deleted , 90467, 90470, 90663, 90742, Q2035, Q2036, Q2037, Q2038, Q2039; removed several age bands Added new preventive services - Breast cancer counseling for genetic testing, Breast pumps, Breast pump supplies, Colon cancer screen (ancillary), Contraceptive counseling, Contraceptive counseling/treatment (emergency), Contraceptive methods, Contraceptive methods (ancillary), Depression screen, Diabetes screen gestational, Sexually transmitted infections counseling, Sterilization, Sterilization (ancillary), Pharmacy contraceptives. 03/19/13 Added code J7302 to Contraceptive Methods. pamspina Page 27 04/12/11

28 03/29/13 Added links to CDC website under Pharmacy and Immunization sections. Aspirin for the prevention of cardiovascular disease: added the word generic, added mg strength, added gender/age band restrictions. Contraceptives: added hyperlink to ConnectiCare Drug Lists on connecticare.com Folic acid supplements for women of child-bearing age: added the word generic, added mg strengths, updated female age band. Iron supplements for children: added the word generic, updated age band Oral fluoride supplements for children: updated to say that coverage includes generic oral dosage forms, added mg strength, updated age band 05/22/13 Added new section to top of grid to explain how to identify municipality variations in this grid using the MUNIPLTY rider. Added MUNIPLTY frequency variations for the following services: Preventive screenings and counseling, AAA screening, alcohol screening, Autism and developmental screening, blood count, breast feeding support, chlamydia screening, creatinine, diabetes screening, gonorrhea screening, gynecological exam, hearing screening, hematocrit/hemoglobin screening, HPV screening, lead screening, lipid screening, mammography, newborn screenings for hypothyroidism, newborn screenings for PKU, newborn screenings for sickle cell disease, osteoporosis screening, pap smear, pregnancy screening panel, syphilis screening, TB testing, urinalysis, venipuncture. Removed EKG reference from comments of preventive screenings & counseling section Added new preventive MUNIPLTY services for Assay Vitamin D, EKG, Executive Profile, General Health Panel & Prostate Cancer Screening. Added MUNIPLTY exempt from all cost shares for the following services: Blood Count, Creatinine, Lead Screening, Lipid screening, TB testing, Urinalysis, Venipuncture & vision screening in all ages. Added DX codes V20.0, V20.1, V20.3, V20.31 & V20.32 for MUNIPLTY coverage to lipid screening & venipuncture. Added MUNIPLTY coverage to Mammography (Baseline) unlimited and exempt from all cost share. 06/14/13 Removed diagnosis codes V72.3 & V72.31 from Prostate Cancer Screening. 08/15/13 Created new entry for Breast cancer, genetic testing (BRCA) Added procedure codes & 453 to Colon cancer screening (procedures) section Created new entry for Maternity, initial visit Created new entry for Physical Therapy Within the pharmacy section added entries for Bowel Prep Agents and Vitamin D coverage 09/23/13 Added Immunization Procedure Codes for Influenza (flu) Vaccine: 90661, 90672, 90685, 90686, Q2033, (eff 1/1/14). 11/19/13 Added the following codes effective 8/1/13 to contraceptive services: J1050, J7300, J7307 & Q /23/13 Added Immunization Procedure Code for Influenza (flu) Vaccine: /21/14 Added new row for Maternity, antepartum/prenatal care exempt from all cost share: & Added to the Important Note section: exemptions are for in-network level only pamspina Page 28 04/12/11

29 06/10/14 Added procedure codes & to Hearing screening section Created new entry for Hepatitis C Screening which includes location codes within the guidelines Created new entry for Lung cancer Screening which includes location codes within the guidelines Added additional line in the Contraceptive methods section for which includes location codes within the guidelines 06/25/14 Within pharmacy section added new entry for Breast Cancer Primary Prevention coverage. 12/29/14 Abdominal Aortic Aneurysm (AAA) Screening changes effective with DOS 1/1/15 replaced DX V.2 with V15.82 and limited to locations 11 & 22. Added new entry for Dental Caries Prevention (effective with DOS 1/1/15) which includes location codes within guidelines Added new entry for Hepatitis B Screening (effective with DOS 1/1/15) which includes location codes within guidelines Smoking Cessation changes effective with DOS 1/1/15 removed deleted codes C9801 & C9802; added DX & 649.0; limited to locations 11, 22 professional services only & 50; added coverage for telephone consultations and increased visit maximum from 1 per year to 8 per year. 01/14/15 Updated 5 th column to Location/Comment Moved location from Guidelines column to Location/Comment column for the following services: AAA screening, contraceptive methods, dental caries, Hepatitis B & C screenings, lung cancer screening and smoking cessation Removed reference to professional services only in LC -22 for Hepatitis B screening & smoking cessation 02/04/15 Updated code by removing the word infant and adding 7 valent 02/08/15 Added for influenza effective 1/1/15 and for Meningitis effective 2/1/15 02/16/15 Updated all location codes. Contraceptive counseling: removed 992, 99282, 99283, and Dental Caries Prevention: removed D1206 and added Osteoporosis Screening: removed 77079, and added /23/15 Sexually transmitted infections, counseling coverage expanded to include males effective 7/1/15 Pharmacy section - Added Aspirin for the prevention of preeclampsia effective 8/1/15 Expanded breast pump coverage to include E0603 (electric -non hospital grade) effective 7/1/15 pamspina Page 29 04/12/11

30 07/16/15 Autism: Added code Colon cancer screening: Added codes 44401, 45346, 45388, G6019, G6022, G6024 and deleted codes 44393, 45339, Human Papilloma Virus (HPV) screening: Added codes 87623, 87624, and deleted 87620, 87621, HIV testing: Added code Dental Caries Prevention: Added code and deleted D1206 Note: this is a change from original Config Contraceptive methods: Added code J7301 with Note that code was effective 1/1/14 and deleted code Q0090 Osteoporosis screening: Added code and deleted codes and Influenza (flu) Vaccine: Added code HPV(Human Papillomavirus) Vaccine: Added code with Frequency and Age Band requirements Meningitis Vaccine: Added codes and Abdominal Aortic Aneurysm (AAA) screening: Added location code 50 Important note added at top of document with disclaimer that configuration may not have been completed when the publication was updated. 9/8/15 Added ICD10 codes HPV(Human Papillomavirus) Vaccine: Modified code Age Band requirements 09/18/15 Updated Influenza Vaccine section removed effective dates, and deleted codes Q2033 and 90660, Added code to the main Influenza section and added to the Flu Mist section. 11/21/15 Removed Gender references from Abdominal Aoritc Aneurysm screening, Breast Cancer Screening codes, Breast feeding support codes, Breast Pump codes, Chlamydia screening, Contraceptive counseling codes, Diabetes screening gestational codes, Gonorrhea screening codes, Gynecological exam codes, HPV codes, Mammography codes, Maternity codes, Osteoporosis Screening, Pap Smear, Pregnancy codes, Sterilization codes, HPV vaccine codes 12/1/15 Added link to Colonosocpy job aid under Colonoscopy screening section. 12/17/15 Added section on Colonoscopy, Pre-Procedure Screening with a Gastroenterologist effective 1/1/16 02/04/16 Corrected typo on dx codes on Executive profile and General Health panel from Z to Z /11/16 Updated location code on Colonoscopy, Pre-Procedure Screening with a Gastroenterologist to add location code 19 and remove location code 24 03/03/16 Added location code 19 to the grid wherever location code 22 was also present. 03/08/16 Added location code 11 to Assay Vitamin D, Executive Profile, General Health Panel and Prostate Cancer Screening. Added code (effective 12/1/15) to Influenza section. 04/11/16 Added 800 to the Pregnancy Screening Panel effective 1/1/2016. Also added location code 71 & 72 05/03/16 Added J7297 & J7298 effective 1/1/16 to the contraceptive methods section, Deleted J7302 from this section effective 1/1/16 05/07/16 Added Assay Thyroid section effective 7/1/16, Added location 71 & 72 effective 1/1/14 09/12/16 Added location 11 to Sterilization Services effective 9/1/16 11/05/16 Removed from Influenza Vaccine section effective 9/1/16 pamspina Page 30 04/12/11

31 12/20/16 Added to Influenza Vaccine section effective 8/1/16 12/22/16 Added new entry for breast tomosynthesis screening effective 1/1/17 Updated Pharmacy section as follows: Aspirin combined multiple entries and adjusted age requirement; Bowel preparation Agents added limit of 2 per year; Folic acid supplements updated age requirement from to through 50; Iron supplements for children USPSTF recommendation was removed; and added entry for Smoking Cessation. 01/01/17 Removed G0204, G0206, 77051, 77055, from Mammography and Mammography (Baseline) effective 1/1/17 as they are no longer considered preventive and are no longer exempt from cost share. Added codes effective 1/1/17 as that replaces code 77052, and G /13/17 Removed and replaced it with and under preventive screenings. 04/06/17 Update Mammography & Baseline Mammography to reflect coverage to include diagnostic procedures for municipalities. Added MUNIPLTY: also includes: 77065, 77066, G0204, G0206. Updated Abdominal Aortic Aneurysm (AAA) screening to add code effective 1/1/17 which replaced 76770, and G0389 pamspina Page 31 04/12/11

32 Contact = OPPRAH Administrator 5/1/17 Removed and Sigmoidoscopy from Colon Cancer Screening section Not Preventive Care Not Exempt from Cost Share Removed G6019, G6022 and G6024, S3890 from Colon Cancer Screening Section Deleted Codes 1/1/16 Added CT Colonography to Colon Cancer Screening Section Removed and Mammography Diagnostic, from Mammography section-not Preventive Care Not Exempt from Cost Share- codes deleted 1/1/17 Removed Diagnostic procedure re: Hepatitis C, not a Screening-Not Preventive Care-Not Exempt from Cost Share Added HIV Screening Preventive Care- Exempt from Cost Share Removed 87520, and from Hepatitis C Screening. These are Diagnostic Codes-Not Preventive Care-Not Exempt from Cost Share Removed and HIB (Hemophilus influenza b) section- Deleted Codes as of 1/1/16 Removed (Pneumococcal Vaccine 7 valent) section Not a Valid code as of 1/1/16 Removed Codes Deleted 1/1/2013 Removed 90703, 90704, 90705, 90706, 90707, 90708, 90712, 90718, 90720, 90721, - Codes Deleted 1/1/2016 Added Hepatitis B vaccine covered no cost share. Removed 97001, 97002, 97110, 97112, 97113, 97116, 97150, 97530, G0159, S8990, S9131 Physical Therapy for Fall Prevention.now to apply Cost Share.. as of 1/1/17 Removed G0204 and G0206 Diagnostic Mammography, from Mammography section as of 5/1/17 Added E0604 Breast Pump Section Hospital Grade requires Pre-Auth as Preventive Care as of 5/1/17 Added G0270 Medical Nutrition Therapy for Tele-Health Network as Preventive Care as of 5/1/17 Removed G0436 and G0437 from Smoking Cessation Telephonic Counseling Section Deleted Codes 10/1/2016 Added J7304 and J7306 to Contraceptive Methods Section -5/1/17, were New Codes in 2005 Added S49 and S4989 to Contraceptive Methods Ancillary Section 5/1/17 as preventive care per State of CT regulations 7/21/17 Added to Influenza Vaccine section effective 7/1/17 Added new entry for Latent Tuberculosis Screening (LTBI) effective 10/1/17 9/15/17 Added new entry within Pharmacy section for Cholesterol/Statin Prevention effective 11/1/17 Added Q9984 to Contraceptive Methods effective 7/1/17 Added Kyleena to Contraceptives under Pharmacy section. 10/20/17 Removed code and /10/17 Corrected typo on medical nutrition code. Code was incorrectly typed as G0207 when it should have been G0270. pamspina Page 32 04/12/11