Understanding Preventive Care

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1 Understanding Preventive Care

2 FAQs: Understanding Preventive Care At Blue Cross and Blue Shield of Vermont, (BCBSVT) we want you to get preventive care so you can find out about health problems early and get the treatment you need. Some preventive care can keep you from becoming sick in the first place. This guide explains which preventive care is right for you and how we cover various services. * What is preventive care? Preventive care includes screenings, tests, medicines and counseling performed or prescribed by your doctor or other health care provider when you don t have signs or symptoms of an injury or illness. Other preventive care helps detect health conditions early, so you can change your lifestyle or get treatment to improve your health. We encourage you to get appropriate preventive care for your age and gender. (See the charts in this guide.) What will preventive care cost me? BCBSVT covers certain preventive services at no cost to you (i.e., with no cost-sharing like deductibles, co insurance or co-payments). We provide this benefit for all services rated A or B by the United States Preventive Services Task Force (USPSTF), a board of physicians who have researched preventive services to determine which are the most effective. The benefits apply only if your plan is not grandfathered with respect to the Affordable Care Act.** The charts in this brochure show you which services receive an A or B rating by the USPSTF. You do not have to pay cost-sharing for these services. You do have to pay cost-sharing for preventive services not on this list. What is the difference between preventive and diagnostic medicine? A preventive procedure starts with the intent of confirming your good health when you are apparently free of symptoms or disease. Diagnostic medicine happens when you go to your doctor or other health care provider with symptoms and your provider recommends screenings and tests to diagnose their cause. While we cover these services, you may have to pay deductibles, co-payments and/or co-insurance. Can preventive care turn into diagnostic medicine? Yes. Sometimes a provider begins a preventive screening or test and, during its course, finds or suspects disease. The provider then bills us for a diagnostic procedure. You may have to share in the cost. Also, if you have a history of a particular illness, a screening related to that illness might be considered diagnostic for you, while it may be preventive for other patients. Check out these examples: Scenario 1: A 30-year old woman without symptoms has an annual physical. It includes a breast exam, a Pap smear, cholesterol and glucose screening and screening for sexually transmitted diseases. The Pap smear shows an irregularity. The first exam will be paid at the preventive level. A follow-up exam, done at a later date because of the irregularity of the Pap, will be paid subject to cost-sharing. Scenario 2: You have a lipid test and a metabolic test at your annual physical. You do not have to pay costsharing for the lipid test, but since the metabolic test does not appear on the USPSTF s list of A- and B-rated services, you must share in the cost of the metabolic test. Are there other preventive services that I may need? Yes, you may need other preventive services because of your individual health care needs. The USPSTF bases its recommendations on the needs of the general population. You may have special needs, so we encourage you to consult your doctor or other health care provider about additional preventive care. Preventive Medications (available at no cost; requires prescription) SERVICE EXAMPLES/RESTRICTIONS Aspirin Men, ages 45 79, and women, ages (generic only) Breast Cancer Prevention Women, no age restrictions Contraception Women, no age restrictions (generic only for oral contraceptive medications) Vitamin D Supplements Adults age 65 and over Folic Acid Supplements Women, ages Fluoride Supplements Children, ages 6 mos. 5 years (generic only) Pediatric Iron Supplements Children, ages 6 mos. 12 mos. (generic only) Smoking Cessation Up to 180-day supply of nicotine replacement therapies * For full details, please consult a subscriber contract. ** Coverage that existed before passage of the Affordable Care Act may have different preventive care provisions. If your plan is grandfathered, you will see language explaining allowances in your contract document or on our member resource center. Check your subscriber contract for your benefits or call our customer service team at the number on the back of your ID card.

3 Preventive Care for Men FIND YOUR AGE (YEARS) FOR YOUR: SCREENING OR EXAM TYPE: Height and Weight Body Mass Index (BMI) Intestinal Health Colorectal Cancer * Heart and Vascular Health Metabolic Health Abdominal Aortic Aneurysm Blood Pressure Cholesterol Type 2 Diabetes If you are at increased risk for coronary heart disease. 1 Have your blood pressure checked every 2 years. One-time screening if you have ever smoked. If your sustained blood pressure (treated or untreated) is greater than 135/80 mmhg. Sexual Health HIV Screening If you are at increased risk for HIV infection. 2 Syphilis Screening If you are at increased risk for syphilis infection. Flu Shot Get the flu shot every year. Immunizations Pneumonia Shot Shingles Vaccine Get a pneumonia shot. Medications Aspirin Ask your doctor if you should take aspirin to prevent heart disease. Alcohol Intake Other Screenings Depression 3 Fall Prevention Smoking Cessation Mental health is important for your overall health. Blue indicates that every man within the age range should have this screening, exam or medicine. We cover it with no cost-sharing. Green indicates that there are unique circumstances that may be covered by BCBSVT with no cost-sharing if you qualify. Consult your doctor to see if this screening, exam or medicine is right for you. * If you have a family history of colorectal cancer, you may need screening earlier. 1. USPSTF recommends screening in men aged for lipid disorders if they are at increased risk for coronary heart disease. You may be at increased risk if you smoke, are obese, have diabetes or high blood pressure, have a history of heart disease or blocked arteries, or if a man in your family had a heart attack before age 50 or a woman, before age You may be at increased risk for HIV infection if you have had unprotected sex with multiple partners, you have sex with men, you use or have used injection drugs, you exchange sex for money or drugs or have sex partners who do, you have or had a sex partner who is HIV-infected or injects drugs, you are being treated for a sexually transmitted disease or you had a blood transfusion between 1978 and Ask your doctor if you should be screened for depression, especially if during the past two weeks, you felt down, sad or hopeless or have felt little interest or pleasure in doing things.

4 Preventive Care for Women FOR YOUR: Height and Weight SCREENING OR EXAM TYPE: Body Mass Index (BMI) FIND YOUR AGE (YEARS) Intestinal Health Colorectal Cancer * Blood Pressure Have your blood pressure checked every 2 years. Heart and Vascular Health Cholesterol Recommended if you are at increased risk for coronary heart disease. 1 Strongly recommended if you are at increased risk for coronary heart disease. 1 Bone Health Osteoporosis ** Metabolic Health Type 2 Diabetes If your sustained blood pressure (treated or untreated) is greater than 135/80 mmhg. Women s Health Immunizations Other Screenings Cervical Cancer Chlamydia and Other STDs Screening and Counseling If you are 21 to 65 years old and have been sexually active, have a Pap smear every 1 to 3 years. If you are sexually active and If you are older than 24 years, sexually active and you are at increased risk for infection years. HIV Screening and Counseling If you are at increased risk for HIV infection. 2 HPV Testing Mammogram Syphilis Screening Contraceptives and Contraceptive Counseling Flu Shot Pneumonia Shot Shingles Vaccine Alcohol intake If you are at increased risk for syphilis infection. Generic female contraception methods (or brand name methods if no generic is available)*** Get the flu shot every year. Depression Mental health is important for your overall health. 3 Fall Prevention Smoking Cessation Domestic Violence Get a pneumonia shot. Blue indicates that every woman within the age range should have this screening, exam or medicine. We cover it without cost-sharing. Green indicates that there are unique circumstances that may be covered by BCBSVT with no cost-sharing if you qualify. Consult your doctor to see if this screening, exam or medicine is right for you. * If you have a family history of colorectal cancer, you may need screening earlier. ** Screening is recommended at a younger age if your risk is at the level of a 65-year old. *** Certain church-related organizations may not provide this benefit. Please ask your employer if you think this exception may apply to your plan. 1. Screening is only recommended for women who are at increased risk for coronary heart disease. You may be at increased risk if you smoke, are obese, have diabetes or high blood pressure, have a history of heart disease or blocked arteries, or a man in your family had a heart attack before age 50 or a woman, before age You may be at increased risk for HIV infection if you have had unprotected sex with multiple partners, you have sex with men, you use or have used injection drugs, you exchange sex for money or drugs or have sex partners who do, you have or had a sex partner who is HIV-infected or injects drugs, you are being treated for a sexually transmitted disease or you had a blood transfusion between 1978 and Ask your doctor if you should be screened for depression, especially if during the past two weeks, you felt down, sad or hopeless or have felt little interest or pleasure in doing things.

5 Care During and After Pregnancy As a pregnant woman, you may be worried about your baby s health already. One of the best ways to ensure your baby is healthy is to take care of your own health by frequently checking in with your provider and receiving the appropriate preventive care. Preventive care consists of screenings and exams that look for disease before you have symptoms. The sooner a disease or condition is detected, the sooner you and your baby may have access to better treatment or counseling. The U.S. Preventive Services Task Force (USPSTF) recommends certain additional screenings for pregnant women. The following table is a reference guide of preventive care screenings that should be factored into your usual preventive care screenings, exams and medicines. If you have questions at any point, consult your provider. You may have a unique pregnancy that requires special health care needs. FOR: SCREENING OR EXAM: SPECIFIC GUIDELINES Infectious Disease Asymptomatic Bacteriuria Chlamydial Infection Gonorrhea Hepatitis B Virus Syphilis Infection Screening recommended at weeks gestation or at first prenatal visit, if later. Screening recommended at first prenatal visit for all pregnant women aged 24 or younger and for older pregnant women who are at increased risk. Screening recommended at first prenatal visit for all sexually active, pregnant women. Screening strongly recommended at first prenatal visit. Screening recommended at first prenatal visit. Nutritional Conditions Iron Deficiency Anemia Routine screening recommended. Obstetric Conditions Rh (D) Incompatibility Blood typing and antibody testing strongly recommended at first prenatal visit. Breastfeeding Other Screenings Support and Counseling Supplies Alcohol & Drug Misuse Depression Smoking Cessation Gestational Diabetes You must get Prior Approval for hospital-grade breast pumps Blue indicates that every woman within the age range should have this screening, exam or medicine. We cover it without cost-sharing. Green indicates that there are unique circumstances that may be covered by BCBSVT with no cost-sharing if you qualify. Consult your doctor to see if this screening, exam or medicine is right for you.

6 Children & Adolescents Preventive Care & Immunization Checklists From birth to adolescence, your child has unique healthcare needs. In order to ensure your child stays healthy, it is important to have frequent check-ups with your child s primary care provider to get your child the appropriate screenings and immunizations. The U.S. Preventive Services Task Force (USPSTF) recommends certain screenings for children from birth to 18 years of age. USPSTF uses the Center for Disease Control and Prevention (CDC) as their source for immunization recommendations based on age. BCBSVT covers these preventive services for our members and encourages parents and children to use the following charts as a preventive care reference guide. Your child may have unique healthcare needs or individual circumstances that require additional screenings, exams and/or immunizations. AGE (YEARS) SCREENING AT BIRTH Congenital Hypothyroidism Phenylketonuria (PKU) Sickle Cell Disease Hearing Loss Iron Deficiency Anemia Screening Lipid Screening Visual Impairment Height and Weight (Childhood Obesity) Major Depressive Disorder At least once between 3 and 5 years This may not be right for everyone between 12 and 18 years.* Blue indicates all children should have this screening. We cover it without cost-sharing. * Risk factors that indicate you (or your child) may need screening for Major Depressive Disorder include parental depression, having mental health or chronic medical conditions and having experienced a major negative life event. Immunization Schedule An integral part of early preventive care for young people is proper immunization. During the first year of life, your child loses the immunity received from his or her mother. If an unvaccinated child is exposed to disease, the child s body may not be capable of fighting it. Vaccines help develop immunity to disease by imitating an infection, but this infection does not cause illness. When a child s body develops immunity from vaccination, the body can recognize and fight the disease in the future. The immunizations on the next page are those recommended by the US Preventive Services Task Force and the Center for Disease Control and Prevention. We cover all of the listed immunizations with no cost-sharing.

7 Immunization Schedule * CHILD S AGE VACCINE (DOSE) PROTECTS AGAINST At Birth Hepatitis B (1 of 3) Hepatitis B virus 1-2 months Hepatitis B (2 of 3) 2 months 4 months 6 months 6-18 months DTaP (1 of 5) Hib (1 of 4) Polio (1 of 4) Pneumococcal Conjugate 1 (1 of 4) Rotavirus 2 (1 of 3) DTaP (2 of 5) Hib (2 of 4) Polio (2 of 4) Pneumococcal conjugate (2 of 4) Rotavirus 2 (2 of 3) DTaP (3 of 5) Hib (3 of 4) Pneumococcal conjugate (3 of 4) Rotavirus 2 (3 of 3) Hepatitis B ( 3 of 3) Polio (3 of 4) * This chart provides guidelines for most children. Ask your health care provider about specific recommendations for your child. Diphtheria, tetanus and pertussis (whooping cough) Infections of the blood, brain, joints or lungs (pneumonia) Polio infections of the blood, brain, joints, inner ears or lungs (pneumonia) Rotavirus diarrhea (and vomiting) 6 months or older Influenza (yearly) Flu and complications months Hib (4 of 4) Pneumococcal Conjugate 1 (4 of 4) MMR (1 of 2) Varicella (1 of 2) Measles, mumps, and rubella (German measles) Chickenpox months Hepatitis A (1 of 2) Hepatitis A virus (inflammation of the liver) months DTaP (4 of 5) 18 months or older 4-6 years years Hepatitis A (2 of 2 following 6 months after first dose) DTaP (5 of 5) Polio (4 of 4) MMR (2 of 2) Varicella (2 of 2) Tdap (1 of 1) MCV4 3 (1 of 1) HPV (1 of 3) HPV (2 of 3) HPV (3 of 3) Diphtheria, tetanus and pertussis (whooping cough) Meningococcal conjugate vaccine Human Papillomavirus

8 Blue Cross and Blue Shield of Vermont PO Box 186 Montpelier, VT (10/2015)

9 Your guide to Preventive Services For plans with Affordable Care Act preventive benefits

10 Promoting good health through wellness The value of preventive care. Blue Cross and Blue Shield of Vermont believes in the value of preventive care, like periodic cancer screenings, flu shots and routine physical exams that help detect illness and reduce health risks early on creating healthier individuals and preventing high-cost medical events. We encourage all of our members to get ageappropriate, regularly scheduled preventive care. No cost sharing. To ensure that all of our members have access to preventive health services necessary for their health and well-being and in accordance with the Affordable Care Act (ACA), Blue Cross and Blue Shield of Vermont covers certain preventive health services without a co-payment, co-insurance or deductible for plans with ACA-defined preventive benefits for in-network services. Please see your plan materials for specific details about your coverage. What is a preventive service? Preventive services are exams and certain screenings or tests that look for diseases before you have symptoms. Blood pressure checks and tests for high cholesterol are examples of screenings. By performing a preventive service, a doctor hopes to prevent future illness and detect health concerns early enough to help make a change in lifestyle or obtain appropriate treatment. Coverage of preventive services. Blue Cross and Blue Shield of Vermont follows the United States Preventive Services Task Force (USPSTF) guidelines for preventive services with an A or B rating, as well as the Center for Disease Control s (CDC) recommendations for immunizations. 2

11 Members with preventive benefits defined by the Affordable Care Act receive certain preventive services at no cost share. We have provided a full list of these services, including the expanded coverage of women s preventive services. Adult and Pediatric Immunizations SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS 90460, 90461, 90471, 90472, 90473, 90474, 90654, 90655, 90657, 90662, 90669, 90696, None 90698, 90700, 90715, 90746, G0008, G None 90633, Age , 90646, Age None Age 0-18 G0010 None Adult & Pediatric Immunizations 90647, 90680, Any eligible diagnosis Age 0-1 (according to CDC schedule) 90649, Age , None 90636, 90660, Age , Age less than 6 and Age less than Age Age Age & Age 50+ Preventive Visits All Ages SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS , Any eligible diagnosis Age 17 or less F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, O99.330, O99.331, O99.332, O99.333, & O99.334, O99.335, Z76.1, Z76.2, Z00.121, Z00.129, Age 22+ Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 All Ages Comprehensive Preventive Visits S0610, S0612, S0613, 99386, 99387, 99396, 99397, 99403, 99404, 99408, & F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, O99.330, O99.331, O99.332, O99.333, O99.334, O99.335, Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Any eligible diagnosis Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 None Male 3

12 Adult and Pediatric Health Screenings SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Abdominal Aortic Aneurysm Screening Alcohol Misuse Screening & Behavioral Counseling Interventions G , Any eligible diagnosis Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, None Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 F10.10, F10.120, F10.129, Z00.00, Z00.01 Age 11+ Audiology/Vision Screening 92551, Any eligible diagnosis None Any eligible diagnosis Behavioral Counseling in Primary Care to Promote Healthy Diet Childhood Obesity Screening and Interventions 99401, Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Male Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, 99403, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, None Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z , 97803, 97804, S9452, S9470 Z00.00, Z00.01, Z71.3 None 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Males, age Limit once per lifetime Age 21 or under Congenital Hypothyroidism Screening in Newborns 84436, 84437, 84439, Z00.00, Z00.01, Z13.29 Age less than 1 year Colorectal Cancer Screening G0328, 45330, , G , 45378, 45380, , G0121, Any eligible diagnosis Limit once per plan year 34, , 82270, 82274, Developmental Testing Any eligible diagnosis Limit 5, then prior approval & F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, O99.330, O99.331, O99.332, O99.333, Age 22+ Depression Screening (Adults) O99.334, O99.335, Z76.1, Z76.2, Z00.121, Z00.129, & 99387, & Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, None Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Diabetes Screening 82947, Z00.00, Z00.01, Z13.1 None Fall Prevention 1100F, 1101F, 3288F Any eligible diagnosis Age 65+ Hearing Loss Screening for Newborns 92586, Z00.00, Z00.01, Z00.121, Z00.129, Z01.10, Z01.118, Z31.5 Age less than 1 year 4

13 SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Hepatitis C HIV Screening , 86689, G0432, G0433, G0435 O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.70, O09.71, O09.72, O09.73, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O30.899, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.3, Z12.4, Z12.72, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93 Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O None Age 12+ Limit two per plan year 5

14 Adult and Pediatric Health Screenings SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Iron Deficiency Anemia Screening 80055, 85013, 85014, 85018, 85025, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, Age 2+ O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O Lead Screening Any eligible diagnosis Age less than 6 years Lipid Screening (Cholesterol Screening) Obesity Screening (Adult) 80061, 82465, Z00.00, Z00.01, Z , 99386, 99387, , , , , , , F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, O99.330, O99.331, O99.332, O99.333, O99.334, O99.335, Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Age 2+ Limited once per plan year Age 18+ Phenylketonuria Screening (Children) Z00.00, Z00.01, Z Age less than 1 year Prostate Screening 84066, 84152, 84153, 84154, G0103, G0102 Z00.00, Z00.01, Z12.5 Male, age 40+ Sickle Cell Disease Screening 83020, Z00.00, Z00.01, Z13.0 Age less than 1 year 6

15 SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Syphilis Infection Screening 86592, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z72.51, Z72.52, Z72.53, Z00.00, Z00.01, Z11.3, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O None Tobacco Use Counseling 99406, Any eligible diagnosis None Venipuncture/Specimen Collection 36415, Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 None Visual Impairment Screening in Children Younger than Age Z01.00, Z01.01 Z76.1, Z76.2, Z00.121, Z00.129, Z00.110, Z00.111, Z76.81, Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8, Z01.411, Z01.419, Z13.89, Z13.4, Z13.6 Preventive Medications (available at no cost; requires prescription) SERVICE EXAMPLES/RESTRICTIONS Aspirin Men, ages 45 79, and women, ages (generic only) Breast Cancer Prevention Women, no age restrictions Contraception Women, no age restrictions (generic only for oral contraceptive medications) Vitamin D Supplements Adults age 65 and over Folic Acid Supplements Women, ages Fluoride Supplements Children, ages 6 mos. 5 years (generic only) Pediatric Iron Supplements Children, ages 6 mos. 12 mos. (generic only) Smoking Cessation Up to 180-day supply of nicotine replacement therapies Smoking Cessation Your plan offers a 180-day supply of nicotine replacement therapies Available with a prescription only None 7

16 Women s Health Screenings Women have unique health care needs that change over the course of their lifetime. The Affordable Care Act has expanded women s preventive services to be covered with no member cost share for plans with ACA-defined preventive benefits. SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Asymptomactic Bacteriuria Screening in Pregnant Breast and Ovarian Cancer Susceptibility, Genetic Counseling and Evaluation for BRCA Testing Breast Cancer Screening Breast Feeding Support, Supplies and Counseling Cervical Cancer Screening 87081, 87084, 87086, , 77055, 77056, 77057, 77063, G0202 A4281, A4282, A4283, A4284, A4285, A4286, E0602, E0603, E0604, S , , 88150, , , , G0101, G0123, G0141, G , G0147, G1048, Q0091 Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, Z13.0, Z31.5, Z80.3, Z80.41 Z80.3, Z90.10, Z90.11, Z Z90.13, Z Z12.39, Z85.3 Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.291, O09.292, O09.293, O09.299, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O36.80x0, O36.80x1, O36.80x2, O36.80x3, O36.80x4, O36.80x5, O36.80x9, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z39.1, Z00.00, Z00.01, P92.6, R62.51 Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.51, Z12.4, limit once per plan year, limit once per plan year 8

17 SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Chlamydia Screening Contraceptive Methods , 87110, 87270, , , 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, A4261, A4264, A4266, A4268, J7300, J7302, J7303, J7304, J7305, J7306, J7307, S4981, S4989, S4993, 11976, 11980, 57170, 58300, 58301, 58565, 58600, 58605, 58611, 58615, 58661, 58671, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.8, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O Z00.00, Z00.01, Z30.011, Z30.012, Z30.013, Z30.014, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.49, Z30.8, Z30.9, limit two per plan year DXA Scan Z00.00, Z00.01, Z13.820, 60+ Glucose Screening 82950, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.70, O09.71, O09.72, O09.73, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O30.899, Z00.00, Z00.01, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z

18 Women s Health Screenings SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Gonorrhea Screening 87850, 87590, Hepatitis B Virus Infection Screening for Pregnant O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.70, O09.71, O09.72, O09.73, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O30.899, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.3, Z12.4, Z12.72, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93 Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O30.899, Z21, Z57.8, Z99.2, Z49.31, Z51.12, Z92.25, Z92.29, Z51.11, Z63.6, Z63.79, Z65.0, Z65.1, Z65.2, Z65.3 HIV Screening and Counseling 87390, 87534, 87535, G0432, Z00.00, Z00.01, Z11.4, Z11.59, Z71.7 HPV DNA Testing 87620, 87621, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.51, Z12.4 This document summarizes preventive benefits with an A or B rating put forth by the United States Preventive Services Task Force. For more information about preventive care, visit 10

19 SERVICE PROCEDURE CODES PRIMARY DIAGNOSIS CODES RESTRICTIONS Iron Deficiency Anemia Screening Rh(D) Incompatibility Screening in Pregnant 80055, 85013, 85014, 85018, 85025, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.40, O09.41, O09.42, O09.43, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O

20 Blue Cross and Blue Shield of Vermont PO Box 186 Montpelier, VT Phone: (800) (10/2015)

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