For questions regarding the information in this Administrative Bulletin, please contact your Provider Relations Consultant.

Transcription

1 PROFESSIONAL ADMINISTRATIVE BULLETIN: 2012P Date: July 1, 2012 To: All Capital BlueCross and Capital Advantage Insurance Company Participating Professional Providers All Keystone Health Plan Central Participating Professional Providers Subject: Physician Guidelines for Preventive Services Updates Child Health Maintenance Guidelines Adult Health Maintenance Guidelines (Capital BlueCross PPO, POS, Traditional and Comprehensive; Keystone Health Plan Central HMO) Adult Health Maintenance Guidelines (SeniorBlue HMO and SeniorBlue PPO) Effective Date: July 1, 2012 (Unless otherwise indicated) The Childhood, Adult and Medicare Preventive Health Guidelines are updated and include the most current recommendations from the United State Preventive Services Task Force (USPSTF). For your convenience the guidelines are available in the Practice Guidelines section of the Provider Library on the Capital BlueCross health plan home page via the NaviNet portal. The updated guidelines are attached. NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross QUESTIONS For questions regarding the information in this Administrative Bulletin, please contact your Provider Relations Consultant. ATTACHMS Child Health Maintenance Guidelines Adult Health Maintenance Guidelines (Capital BlueCross PPO, POS, Traditional and Comprehensive, and Keystone Health Plan Central HMO) Adult Health Maintenance Guidelines (SeniorBlue HMO and SeniorBlue PPO) Retain a copy of this Administrative Bulletin with your Provider Manual For the most current information, visit Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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3 CHILD HEALTH MAINTENANCE GUIDELINES* SERVICE RECOMMENDED AGES/FREQUENCY ** Routine History and Physical Examination Exams should include: Newborn screening (including gonorrhea prophylactic topical eye medication and hearing loss) Head circumference (up to 24 months) Height/length and weight Body mass index (BMI; beginning at 2 years of age) Blood pressure (beginning at 3 years of age) Sensory screening for vision and hearing Developmental milestones (screening/surveillance) Iron supplementation (6 to 12 months) at increased risk for iron deficiency anemia**** Autism screening ( months) STD screening (males/females, as appropriate) Anticipatory guidance for age-appropriate issues including: Growth and development, breastfeeding/nutrition, obesity prevention, physical activity and psychosocial/behavioral health Safety, unintentional injuries, firearms, poisoning, media access STDs, HIV, pregnancy prevention Pap screening (for sexually active females) Tobacco, alcohol, and illicit drug use Dental care/fluoride chemoprevention Newborn, 3-5 days, by 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, 3 years, 4 years, 5 years, 6 years, 7 years, 8 years, 9 years, 10 years, years (annually) SCREENINGS RECOMMENDED AGES/FREQUENCY **/*** Newborn screen (including hypothyroidism, sickle cell disease and PKU) At birth Lead screening 9-12 months (at risk) 1 Hemoglobin and Hematocrit 9-12 months (at risk) Urinalysis 5 years (at risk) Lipid screening (risk assessment) Every 2 years, starting at 2 years -- 2, 4, 6, 8 and 10 years Annually, starting at 11 years 11, 12, 13, 14, 15, 16 and 17 years. Fasting Lipid Profile Routinely, at 18 years (younger if risk assessed as high) Tuberculin test Assess risk at every well child visit. test (objective method) Beginning at 3 years; annually Hearing test (objective method) At birth and at 4, 5, 6, 8 and 10 years HIV/syphilis tests (males/females) 18 years and younger (high risk males/females****); suggested testing interval is 1-3 years. Chlamydia test (females) 18 years and younger (sexually active females as well as other asymptomatic females at increased risk**** for infection); annually Gonorrhea test (females) 18 years and younger (high risk sexually active females****); suggested testing interval is 1-3 years. IMMUNIZATIONS RECOMMENDED AGES/FREQUENCY **/*** Rotavirus (RV) 2 months, 4 months, [6 months] [PRODUCT SPECIFIC] Polio (IPV) 2 months, 4 months, 6 18 months, 4 6 years Diphtheria/Tetanus/Pertussis (DTaP) 2 months, 4 months, 6 months, months, 4 6 years Tetanus/reduced Diphtheria/Pertussis (Tdap) years (catch-up through age 18) Human papillomavirus (HPV2/HPV4) (females); (HPV4) (males) years (3 doses) (catch-up through age 18) Measles/Mumps/Rubella (MMR) months, 4 6 years Hemophilus influenza type b (Hib) 2 months, 4 months, [6 months], months [PRODUCT SPECIFIC] Chickenpox (VAR) months, 4-6 years (catch-up through age 18) Hepatitis A (HepA) months (2 doses) (catch-up through age 18) Influenza 6 months-18 years; annually 2 during flu season Pneumococcal (PCV) 2 months, 4 months, 6 months, months Hepatitis B (HepB) Birth, 1 2 months, 6 18 months Meningococcal (MCV4) years, 16 years (catch-up through age 18) This information is provided as an educational resource and the entities listed below assume no liability associated with either its contents or use. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. *Traditional and Comprehensive plans may not provide coverage for all of the services and screenings listed above. Please refer to the certificate of coverage for specific benefit details or the Member may call Customer Service at the number listed on the front of their ID card. **Services that need to be performed more frequently than stated due to specific health needs of the Member and that would be considered medically necessary may be eligible for coverage when submitted with the appropriate diagnosis and procedure(s) and are covered under the core medical benefit. ***Capital BlueCross considers Members to be high risk or at risk in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC). ****Capital BlueCross considers individuals to be high risk or at risk in accordance with the recommendations set forth by the U.S. Preventive Services Task Force (USPSTF)[ 1 Encourage all PA-CHIP Members to undergo blood lead level testing before age 2 years.

4 2 Children aged 8 years and younger who are receiving influenza vaccine for the first time should receive 2 separate doses, both of which are covered. Household contacts and out-of-home caregivers of a high risk Member, including a child aged 0-59 months, should be immunized against influenza. Reference Sources: American Academy of Pediatrics (AAP), U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC) [ Revised 4/11/2012

5 PEDIATRIC WELL CHILD CARE PATI S NAME: AND SAFETY 2-4 Weeks Equal Movements Length Wt. HC Breast Car restraints Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Fem. Art. Sleep position Regards face Head Babysitters Follows to midline Responds to sound Fontanelle Umbilic Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120 F Follow-up on abnormal for bathing Newborn Screens Lungs Hips Smoke detectors Vitamins (breast-fed babies) Urine Stools AND SAFETY 1 Month Equal Movements Length Wt. HC Breast Car restraints Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Fem. Art. Sleep position Regards face Head Babysitters Follows to midline Responds to sound Fontanelle Umbilic Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120 F for bathing Lungs Hips Smoke detectors Urine Stools AND SAFETY 2 Months Lifts head temp. erect Length Wt. HC Breast Sleep patterns when held upright General Appearance Formula Daycare / babysitters Date of Visit Regards face in direct line Fem Art. Sleep position of vision Grasps rattle placed in hand Head Fontanelle Testes Social smile Coos Lungs Hips Responds to sound Fall prevention Urine Stools 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

6 PEDIATRIC WELL CHILD CARE PATI S NAME: AND SAFETY 4 Months Holds head high Length Wt. HC Breast Sleep position Raises body on hands General Appearance Formula Reinforce falls prevention Date of Visit when prone Avoid small objects Rolls prone to supine Plays with hands Follows parent with eyes Smiles, coos, laughs, squeals, gurgles Head Fontanelle Lungs Fem Art. Hips Cereal Stools AND SAFETY 6 Months Sits with support Length Wt. HC Breast Passes hand to hand General Appearance Formula Check home for hazards Date of Visit Rolls over Head hot liquids, electrical outlets, Reaches for toys Bears weight Raking hand pattern Babbles, laughs Turns to voice Fontanelle EOM Fem Art. Hips Puréed foods (including Sleep position Lungs iron sources) Crib safety poisons, medicines, dangling cords or table covers Provide Poison Control phone # Car restraints AND SAFETY 9 Months Sits well Length Wt. HC Breast Home safety Crawls, creeps General Appearance Formula Avoid popcorn, nuts, raw carrot Date of Visit Pulls to stand Head Table Food or celery sticks, raw apple, raisins Assisted walking Inferior pincer grasps - pokes Bangs two toys together Pat-a-cake Peek-a-boo Imitates speech sounds Dada Mama Fontanelle Lungs Hips Self-feeding Toast ing bisc. Wean to cup or tiny pieces of toys Family/social dynamics Tooth care Car restraints Stools 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

7 PEDIATRIC WELL CHILD CARE PATI S NAME: AND SAFETY 12 Months Pulls to stand Length Wt. HC Breast SAFETY -- poison-proofing; Walks w/support or few General Appearance Milk stair safety, water safety, auto seat Date of Visit steps alone Head (whole milk) restraints; fences and gates Precise pincer grasp Points Has 1-3 new words plus Dada Mama Looks for dropped or hidden objects Fontanelle Lungs Hips Table foods Continue weaning to cup Tooth care MVI 15 Months Walks alone Length Wt. HC Milk REEMPHASIZE: Crawls up stairs General Appearance Toothcare Puts raisin in bottle Fem Art. No bottle in Date of Visit Points to 1-2 body parts bed Tantrums/behavior Gestures Head Finger foods Understands simple Fontanelle Testes commands Uses cup Lungs Gait MVI Home/environment safety Socialization 18 Months Walks up stairs with help Length Wt. HC Mealtime not STRESS FIRMLY: Sits in a chair General Appearance to be a battle Stairs & window safety Date of Visit 3-4 Cube tower Uses spoon Head Fontanelle Discourage snacks Avoid playing in street/driveway Imitates a crayon stroke 4-10 words May tell 2 or more wants Testes Gait Toothcare Don t leave alone in car or home Guard against falls, electrical injuries, drowning Knows body parts Autism screening Lungs MVI Sleep patterns & night fears Toothbrushing 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

8 PEDIATRIC WELL CHILD CARE PATI S NAME: 24 Months Walks up steps Ht. Wt. HC Avoid fights STRESS DANGERS: Burns, falls Jumps in place General BMI Over eating from windows, cabinets, furniture; Sits in a chair Lungs No snacks eat and drink when sitting; poison Date of Visit 5-6 Cube tower danger; avoid machinery, plastic Makes horizontal or circular strokes 50+ Words Knows name Head Hearing MVI bags Read to child Toilet training What s that? Parents understand child s speech Autism screening Poison control information 30 Months Walks up steps Ht. Wt. HC Avoid fights STRESS DANGERS: Burns, falls Jumps in place General BMI Over eating from windows, cabinets, furniture; Sits in a chair Lungs No snacks eat and drink when sitting; poison Date of Visit 5-6 Cube tower danger; avoid machinery, plastic Makes horizontal or circular strokes 50+ Words Knows name Head Hearing MVI bags Read to child Toilet training What s that? Parents understand child s speech Able to pedal Poison control information 3 Years Kicks ball Ht. Wt. BP Avoid junk Car seat Pedals tricycle General BMI drinks & food Opens door Feeds self Date of Visit 9 Cube tower Head Lungs entirely Water safety Copies circle Does some dressing Feeds self EOM Knows full name, age, sex Counts to three Comprehends tired, cold, hungry test Dental care & referral MVI Knives out of reach Stay out of streets Read to child Speech or language evaluation 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

9 PEDIATRIC WELL CHILD CARE PATI S NAME: 4 Years Hops, jumps forward Ht. Wt. BP Family talk REEMPHASIZE: Water safety; Climbs ladder General BMI mealtimes street crossing and/or play; Can cut & paste Offer small booster seat, and/or appropriate Date of Visit Knows 3 or 4 colors Head Lungs portions seat belt placement; avoid Dresses & undresses w/supervision Counts to 10 Gender ID EOM test Seconds available strangers; home fire safety; sleep in own bed Marble & card games; bed time Draws person - 3 parts Copies cross, circle & maybe square Dental care MVI ritual; nursery school, daycare, babysitting Car booster seat Bike helmet 5 Years Hops on one foot Ht. Wt. BP Balanced diet Seat belts Dresses & undresses self General BMI Can throw and catch a Date of Visit bean bag Head Lungs Separates from parents Gallops, begins skipping, Family dynamics alterntaing feet EOM Bike helmet Prints some letters and Car booster seat numbers test Hearing test Dental care MVI Street sense School experiences/readiness 6 Years Rides bicycle Ht. Wt. BP Balanced diet Bike/traffic safety Laces and ties shoes General BMI Monitor Home environment Growing capacity for self- snacks School environment Date of Visit regulation of behavior Head Lungs Car booster seat Can answer phone, take simple messages School experiences EOM Abdom Firearm safety Exercise Genit Dental care test Hearing test MVI 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

10 PEDIATRIC WELL CHILD CARE PATI S NAME: 7 Years Rides bicycle Ht. Wt. BP Balanced diet Bike/traffic safety Laces and ties shoes General BMI Monitor Home environment Growing capacity for self- snacks School environment Date of Visit regulation of behavior Head Lungs Car booster seat Can answer phone, take simple messages School experiences EOM Abdom Firearm safety Exercise Genit Dental care test Hearing test MVI 8 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 9 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

11 PEDIATRIC WELL CHILD CARE PATI S NAME: 10 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 11 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 12 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

12 PEDIATRIC WELL CHILD CARE PATI S NAME: 13 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development General BMI Monitor Home environment Intellectual development snacks Puberty Date of Visit Social development HE Exercise Community Interests Peer pressure Family dynamics Seat belt placement test Dental care Firearm safety MVI 14 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development General BMI Exercise Education Injury prevention; firearms Date of Visit Social relationships HE MVI Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE test Dental care Chlamydia/STD screening Pelvic exam Pap 15 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General BMI evaluation Exercise Injury prevention; firearms Date of Visit Social relationships HE MVI Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE test Dental care Chlamydia/STD screening Pelvic exam Pap 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

13 PEDIATRIC WELL CHILD CARE PATI S NAME: 16 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General BMI evaluation Exercise Injury prevention; firearms Date of Visit Social relationships HE MVI Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE test Dental care Chlamydia/STD screening Pelvic exam Pap 17 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General BMI evaluation Exercise Injury prevention; firearms Date of Visit Social relationships HE MVI Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE test Dental care Chlamydia/STD screening Pelvic exam Pap 18 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General BMI evaluation Exercise Injury prevention; firearms Date of Visit Social relationships HE MVI Nutrition Pregnancy prevention Sexually transmitted diseases test TSE/BSE Chlamydia/STD screening Dental care Pelvic exam Pap 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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15 Commercial Adult Health Maintenance Guidelines* SERVICE RECOMMENDED AGES/FREQUENCY ** Routine History and Physical Examination, including BMI and pertinent patient education Adult counseling and patient education include: Women Men Folic Acid (childbearing age) Prostate Cancer Screening Contraceptive methods/counseling Mammography Screening HRT (risk vs. benefits) BRCA counseling (high risk)**** Breast Cancer chemoprevention (high risk)**** Breastfeeding support/counseling/supplies For Both Tobacco Use STIs Seat Belt Use Aspirin prophylaxis (high risk)**** SCREENINGS Obesity/Healthy diet screening/counseling Physical Activity Drug and Alcohol Use Unintentional Injuries Family Planning Pelvic Exam/Pap Smear [USPSTF cytology option] 5 Pelvic Exam/Pap Smear [USPSTF cytology option] 5 Pelvic Exam/Pap Smear/HPV DNA [USPSTF co-testing option] 5 Pelvic Exam/HPV DNA (women) [IOM option] 5 Chlamydia Test (women) Gonorrhea Test (women) WOMEN --19+: at least annually MEN : once 30 49: every 4 years 50+: annually Depression Calcium/vitamin D Intake Fall Prevention Domestic/Interpersonal Violence RECOMMENDED AGES/FREQUENCY**/*** Age 19 and older (high risk)****; every year Age 21 29; every 3 years Age 30 65; every 3 years Age 30 65; every 5 years Beginning at 30; every 3 years Age 19-24: Test all sexually active females; annually Age 25 and older: Test all females at increased risk;**** suggested testing interval is 1 3 years Age 19 and older: Test all high risk sexually active females;**** suggested testing interval is 1-3 years. HIV/syphilis Tests (men/women) Age 19 and older: Test all high risk men/women;**** suggested testing interval is 1 3 years Blood Pressure Age 19 and older: every 2 years (with BP < 120/80) Diabetes Screening Test Beginning at 19 (high risk)****; every 3 years Fasting Lipid Profile Beginning at 20; every 5 years Fecal Occult Blood Test 1 Beginning at 50; annually Flexible Sigmoidoscopy 2 Beginning at 50; every 5 years Colonoscopy 2 Beginning at 50; every 10 years Barium Enema X-ray 3 Beginning at 50; every 5 years Prostate Specific Antigen Offered beginning at 50 and annually thereafter Abdominal Ultrasound (men) Age 65 75; one-time screening for abdominal aortic aneurysm in men who have ever smoked Mammogram Bone Mineral Density (BMD) Testing (women) IMMUNIZATIONS Tetanus/diphtheria/pertussis (Td/Tdap) Human papillomavirus (HPV2/HPV4) (women); (HPV4) (men) Hepatitis A (HepA) Hepatitis B (HepB) Influenza 4 Meningococcal (MCV4/MPSV4) Pneumococcal (polysaccharide) (PPSV) Measles/Mumps/Rubella (MMR) Varicella (Chickenpox) Zoster (Shingles) Beginning at 40; every 1-2 years Age 19 64; testing every 2 years may be appropriate for women at high risk.**** Beginning at 65; every 2 years RECOMMENDED AGES/FREQUENCY**/*** 19+; Td every 10 years (substitute one dose of Tdap for Td; for 65+ and close contacts of infants, see CDC) 19 26; three doses (if not previously immunized; for men 22-26, see CDC) 19+; two doses (high risk; see CDC) 19+; three doses (high risk; see CDC) 19+; one dose annually during influenza season 19+; one or more doses: (college students and others at high risk not previously immunized; see CDC) 19 64; one or two doses (high risk; see CDC) Beginning at 65; one dose (if not previously immunized; see CDC) 19-54; one or two doses, give as necessary based upon past immunization or medical history 55+; one or two doses (high risk; see CDC) Beginning at 19; two doses, give as necessary based upon past immunization or medical history Beginning at 50; one dose, regardless of prior zoster episodes (see CDC) This information is provided as an educational resource and the entities listed below assume no liability associated with either its contents or use. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. *Traditional and Comprehensive plans may not provide coverage for all of the services and screenings listed above. Please refer to the certificate of coverage for specific benefit details or the Member may call Customer Service at the number listed on the front of their ID card.

16 **Services that need to be performed more frequently than stated due to specific health needs of the member and that would be considered medically necessary may be eligible for coverage when submitted with the appropriate diagnosis and procedure(s) and are covered under the core medical benefit. Occupational, school and other administrative exams are not covered. ***Capital BlueCross considers individuals to be high risk or at risk in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC)[ ****Capital BlueCross considers individuals to be high risk or at risk in accordance with the recommendations set forth by the U.S. Preventive Services Task Force (USPSTF)[ 1 For guaiac-based testing, six stool samples are obtained (2 samples on each of 3 consecutive stools, while on appropriate diet, collected at home). For immunoassay testing, specific manufacturer s instructions are followed. 2 Only one endoscopic procedure is covered at a time, without overlap of the recommended schedules. 3 Barium enema is listed as an alternative to a flexible sigmoidoscopy, with the same schedule overlap prohibition as found in footnote #2. 4 Capital BlueCross has extended coverage of influenza immunization to all individuals with the preventive benefit regardless of risk. 5 Recommendations of both the USPSTF and the IOM are included in order to aid clinicians in counseling their patients about preferred or acceptable preventive strategies. It should be noted that screening for cervical cancer should not be the sole health care concern when conducting ongoing well-woman visits. Reference Sources: U.S. Preventive Services Task Force (USPSTF); National Institutes of Health (NIH); NIH Consensus Development Conference Statement, March 27 29, 2000; Advisory Committee on Immunization Practices (ACIP); Centers for Disease Control and Prevention (CDC); American Diabetes Association (ADA); American Cancer Society (ACS); The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7); Institute of Medicine (IOM); U.S. Food and Drug Administration (FDA) Revised 4/11/2012

17 SeniorBlue and SeniorBlue PPO Adult Health Maintenance Guidelines* SERVICE Initial Preventive Physical Examination (IPPE) ( Welcome To Medicare Physical Exam) includes medical/social history review, depression screen, functional ability and safety screen, height, weight, BMI, blood pressure, visual acuity screen, end-of-life planning, screening EKG, and education, counseling, and referral for other Medicare-covered preventive services as appropriate Yearly Wellness Examination Obesity Screening/Counseling Depression Screening Alcohol Misuse Screening/Counseling Smoking/Tobacco-Use Cessation Counseling Cardiovascular Disease (CVD) Counseling Sexually Transmitted Infections (STIs) Counseling SCREENINGS Total Cholesterol High Density Lipoprotein Low Density Lipoprotein 2 Triglycerides Fasting Plasma Glucose and/or Post-glucose Challenge Test 1 HIV Test STI Testing RECOMMENDED AGES/FREQUENCY Once per lifetime, within 12 months of enrollment in a Medicare Part B program, provided that coverage began on or after January 1, 2005 Medicare s quick reference chart describing the IPPE in more depth is available: Medicare s quick reference chart describing all preventive services, including applicable medical codes, is available: Once per year; must begin at least 12 months after above exam If BMI > 30, one face-to-face Intensive Behavioral Therapy (IBT) counseling visit weekly for the first month followed by one counseling visit every other week for months 2-6; if > 6.6 pound weight loss is documented by end of month 6, then one additional counseling visit every month for months 7-12 One screening per year Once screening per year; if positive, up to a maximum of four brief face-to-face counseling sessions per year Twice per year (each cessation attempt includes a maximum of four counseling visits per attempt), regardless of any tobacco-related illness or complication One face-to-face CVD risk reduction visit per year for Intensive Behavioral Therapy (IBT) counseling Two face-to-face STI prevention visits per year for High Intensity Behavioral Counseling (HIBC) RECOMMENDED AGES/FREQUENCY Once every 5 years Once every 5 years Once every 5 years Once every 5 years Two screening tests every calendar year for pre-diabetic Members One screening test every year for all others at high risk 1 for diabetes One screening test every year for men and non-pregnant women at increased risk 10 for infection One screening test every year for men at increased risk 10 for syphilis One screening test every year for non-pregnant women at increased risk 10 for Chlamydia, gonorrhea and syphilis Once per year for male Members age 50 and older Digital Rectal Exam with Prostate Specific Antigen Test Pelvic Exam with Pap Smear Once per year for all female Members, regardless of cancer risk 2 Glaucoma Exam One screening every year for Members at high-risk 3 Routine Hearing Test 2 Once per year

18 SeniorBlue and SeniorBlue PPO Adult Health Maintenance Guidelines* One-time screening for abdominal aortic aneurysm (AAA) for male Members Abdominal Ultrasound ages who have smoked at least 100 cigarettes in their lifetime or for Members of any age/gender with a family history of AAA Mammogram One initial baseline screening for female Members ages One screening every year for female Members age 40 and older Bone Mass Measurement One screening test every 2 years for high-risk 4 Members Fecal Occult Blood Test 5 Once per year for Members age 50 and older Flexible Sigmoidoscopy Once every 4 years for Members age 50 and older (unless the Member does not meet the criteria for high risk 5 for colorectal cancer and the Member had a screening colonoscopy within the past 10 years) Colonoscopy Once every 2 years for Members at high risk 6 for colorectal cancer Once every 10 years for Members not at high risk 6 for colorectal cancer (unless the Member had a covered screening flexible sigmoidoscopy within the past 4 years) Barium Enema X-ray 7 Once every 2 years for Members at high risk 6 for colorectal cancer Once every 4 years for Members age 50 and older not at high risk 6 for colorectal cancer (unless the Member does not meet the criteria for high risk 6 for colorectal cancer and the Member had a screening colonoscopy within the past 10 years) IMMUNIZATIONS RECOMMENDED AGES/FREQUENCY Influenza (Flu) [includes H1N1] Once per year (during flu season) Pneumococcal (PPV) Once for Members age 65 and older 8 Hepatitis B (HBV) Once (series) for Members at high or intermediate risk for hepatitis B 9 This information is provided as an educational resource and the entities listed below assume no liability associated with either its contents or use. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. * Services that need to be performed more frequently than stated due to specific health needs of the Member and that would be considered medically necessary may be eligible for coverage when submitted with the appropriate diagnosis and procedure(s) and are covered under the core medical benefit Members with one of the following are eligible: hypertension, dyslipidemia, obesity (BMI > 30), or prior diagnosis of elevated impaired fasting glucose or glucose intolerance. Members with two of the following are also eligible: overweight (BMI > 25 but < 30), family history of diabetes, age 65 years or older, or personal history of gestational diabetes or giving birth to a baby weighing > 9 pounds. These three elements are provided in excess of traditional Medicare Part B coverage. High-risk criteria are: a family history of glaucoma; or personal history of diabetes; or African-American age 50 and older; or Hispanic-American age 65 and older. Members with any of the following are eligible: estrogen-deficient female Members at risk for osteoporosis, Members with certain spinal abnormalities evident by x-ray, Members receiving long-term corticosteroid therapy, Members with primary hyperparathyroidism, or Members being monitored to assess the response to or efficacy of a FDA-approved osteoporosis drug therapy.

19 SeniorBlue and SeniorBlue PPO Adult Health Maintenance Guidelines* For guaiac-based testing, six stool samples are obtained (2 samples on each of 3 consecutive stools, while on appropriate diet, collected at home). For immunoassay testing, specific manufacturer s instructions are followed. High-risk criteria are: a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; or a family history of familial adenomatous polyposis; or a family history of hereditary nonpolyposis colorectal cancer; or a personal history of adenomatous polyps; or a personal history of colorectal cancer; or inflammatory bowel disease, including Crohn s Disease and ulcerative colitis. Covered as an alternative to either a screening flexible sigmoidoscopy or a screening colonoscopy. Capital BlueCross considers Members to be high risk in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC) [ As such, some Members may need to receive PPV at an earlier age and some may also be eligible for reimmunization. Capital BlueCross considers Members to be high risk in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC) [ 10 Increased risk criteria are based upon US Preventive Services Task Force (USPSTF) guidelines and include any Medicare beneficiary who asks for the testing [www. Reference Sources: Centers for Medicare & Medicaid Services; HGS Administrators; Centers for Disease Control and Prevention (CDC) Revised: 4/11/2012