Date: April 1, 2015 All Keystone Health Plan Central Participating Subject: Physician Guidelines for Preventive Services

PROFESSIONAL ADMINISTRATIVE BULLETIN: 2015P-04-001 Date: April 1, 2015 All Keystone Health Plan Central Participating Subject: Physician Guidelines for Preventive Services Professional Providers Child Preventive Health Maintenance Guidelines Adult Preventive Health Maintenance Guidelines Adult Health Maintenance Guidelines (SeniorBlue HMO and SeniorBlue PPO) To: All Capital BlueCross and Capital Advantage Insurance Company Participating Professional Providers Capital Advantage Assurance Company Participating Professional Providers Effective Date: April 1, 2015 (Unless otherwise indicated) Childhood, Adult and Medicare Preventive Health Guidelines are updated and include the most current recommendations from the United States Preventive Services Task Force (USPSTF). Refer to the Alpha footnotes for the effective dates of some of the new USPSTF guidelines. 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. ATTACHMENTS Child Preventive Health Maintenance Guidelines Adult Preventive Health Maintenance Guidelines 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 the Capital BlueCross health plan home page via the NaviNet provider communications portal at: https://navinet.navimedix.com/mail.aspx Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company, and Keystone Health Plan Central. Independent licensees of the Blue Cross Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies

CHILD PREVENTIVE HEALTH MAINTENANCE GUIDELINES* SERVICE RECOMMENDED AGES/FREQUENCY ** Routine History and Physical Examination Initial/Interval 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 milestone surveillance (except at times of developmental screening) Iron supplementation (6 to 12 months) at increased risk for iron deficiency anemia**** 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 Pregnancy prevention Tobacco products Dental care/fluoride supplementation (> 6 months) A,3 Fluoride varnish painting of primary teeth (every 6 months to age 5 years) A Sun/UV radiation skin exposure 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 to 18 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 Developmental screening At 9 months, 18 months and 2½ years Autism screening At 18 months and 2 years Hemoglobin and Hematocrit At 12 months: routine one-time testing Assess risk at all other well child visits 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 Fasting Lipid Profile Routinely, at 18 years (younger if risk assessed as high) Tuberculin test Assess risk at every well child visit Vision test (objective method) Beginning at 3 years: annually Hearing test (objective method) At birth and at 4, 5, 6, 8 and 10 years Depression screening (PHQ-2) Beginning at 11 years: annually Alcohol and drug use assessment (CRAFFT) Beginning at 11 years: annually STI/HIV screening risk assessment Beginning at 11 years: annually STI counseling B Beginning at 11 years (sexually active): offer Intensive Behavioral Therapy (IBT) counseling Syphilis test 18 years and younger (high risk children****): suggested testing interval is 1-3 years Beginning at 11 years (children who have not been vaccinated for hepatitis B virus Hepatitis B test A (HBV) infection and other high risk**** children) Periodic repeat testing of children with continued high risk**** for HBV infection Age 15-18: routine one-time testing HIV test Regardless of age: repeat testing of all high risk children;**** suggested testing interval is 1 5 years Chlamydia test (females) B 18 years and younger (sexually active): suggested testing interval is 1-3 years Gonorrhea test (females) B 18 years and younger (sexually active): 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, 15 18 months, 4 6 years Tetanus/reduced Diphtheria/Pertussis (Tdap) 11 12 years (catch-up through age 18) Human papillomavirus (HPV2/HPV4 -- females); (HPV4 -- males) 11--12 years (3 doses) (catch-up through age 18) Measles/Mumps/Rubella (MMR) 12 15 months, 4-6 years (catch-up through age 18) Hemophilus influenza type b (Hib) 2 months, 4 months, [6 months], 12 15 months [PRODUCT SPECIFIC] Varicella/Chickenpox (VAR) 12-15 months, 4-6 years (catch-up through age 18) Hepatitis A (HepA) 12--23 months (2 doses) (catch-up through age 18) Influenza 6 months-18 years; annually 2 during flu season Pneumococcal conjugate (PCV13) 2 months, 4 months, 6 months, 12 15 months Pneumococcal polysaccharide (PPSV23) 2-18 years (1 or 2 doses) [high risk: see CDC] Hepatitis B (HepB) Birth, 1 2 months, 6 18 months (catch-up through age 18) Meningococcal (MenACWY-D/MenACWY-CRM) [high risk: see CDC] 11--12 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, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield 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)[www.ahrq.gov/clinic/uspstfix.htm] A Implementation date: May 2015 B Implementation date: September 2015 1 Encourage all PA-CHIP Members to undergo blood lead level testing before age 2 years. 2 Children aged 8 years and younger who are receiving influenza vaccines 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. 3 Fluoride supplementation pertains only to children who reside in communities with inadequate water fluoride. 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) [www.cdc.gov] v2015.2 Revised 3/11/2015

Adult Preventive 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) Breast Cancer chemoprevention (high risk)**** Breastfeeding support/counseling/supplies For Both Tobacco use STIs (see below) Seat Belt use Aspirin prophylaxis (high risk)**** SCREENINGS Obesity Physical Activity Drug and Alcohol use Unintentional Injuries Family Planning Sun/UV radiation skin exposure Obesity/overweight + cardiovascular risk factor combination C 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 STI counseling D Depression Calcium/vitamin D intake Fall Prevention Domestic/Interpersonal Violence WOMEN --19+: at least annually MEN -- 19 29: once 30 49: every 4 years 50+: annually RECOMMENDED AGES/FREQUENCY**/*** Age 19 and older; (BMI > 30 kg/m 2 ): offer Intensive Behavioral Therapy (IBT) counseling Age 19 and older (high risk);**** (BMI > 25 kg/m 2 ): offer Intensive Behavioral Therapy (IBT) counseling to promote a healthful diet and physical activity 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 and older (high risk adults);**** offer Intensive Behavioral Therapy (IBT) counseling Chlamydia Test (women) Age 19-24: Test all sexually active women; suggested testing interval is 1 3 years Age 25 and older: Test all women at increased risk;**** suggested testing interval is 1 3 years Gonorrhea Test (women) Age 19-24: Test all sexually active women; suggested testing interval is 1 3 years Age 25 and older: Test all women at increased risk;**** suggested testing interval is 1 3 years Syphilis Test (men/women) Age 19 and older: Test all high risk men/women;**** suggested testing interval is 1 3 years HIV Test (men/women) Age 19-65: Routine one-time testing of adults not known to be at increased risk for HIV infection Age 19 and older: Repeat testing all high risk adults;**** suggested testing interval is 1 5 years Age 19 and older: adults who have not been vaccinated for hepatitis B virus (HBV) infection and other high Hepatitis B Test A risk**** adults Periodic repeat testing of adults with continued high risk**** for HBV infection Hepatitis C Test Offer one-time testing of adults born between 1945 and 1965 Periodic repeat testing of adults with continued high risk**** for HCV infection Blood Pressure Age 19 and older: every 2 years (general > 60: < 150/90; general < 60 and all others: < 140/90) Diabetes Screening Test (type 2) Beginning at 19; test asymptomatic adults with sustained BP > 135/80 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 Offer beginning at 50 and annually thereafter Low-dose Chest CT Scan Age 55-80 (high risk adults);**** Annual testing until smoke-free for 15 years. Abdominal Duplex Ultrasound (men) B Age 65 75; one-time screening for abdominal aortic aneurysm in men who have ever smoked BRCA screening/counseling/testing [as needed] Beginning at 19 (high risk women);**** reassess screening every 5-10 years Mammogram Beginning at 40; every 1-2 years Bone Mineral Density (BMD) Testing (women) Age 19 64; testing every 2 years may be appropriate for women at high risk.**** Beginning at 65; every 2 years IMMUNIZATIONS RECOMMENDED AGES/FREQUENCY**/*** Tetanus/diphtheria/pertussis (Td/Tdap) Human papillomavirus (HPV2/HPV4 -- women); (HPV4 -- men) Hepatitis A (HepA) Hepatitis B (HepB) Hemophilus influenza type b (Hib) Influenza 4 Meningococcal (MCV4/MPSV4) Pneumococcal (conjugate) (PCV13) 19+; Td every 10 years (substitute one dose of Tdap for Td, regardless of interval since last booster) 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 or 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 dose (high risk***; see CDC; serial administration with PPSV23 may be indicated)

Pneumococcal (polysaccharide) (PPSV23) Measles/Mumps/Rubella (MMR) Varicella (Chickenpox) Zoster (Shingles) Beginning at 65; one dose (only if PCV13-naive; see CDC; serial administration with PPSV23 may be indicated) 19 64; one or two doses (high risk***; see CDC; serial administration with PCV13 may be indicated) Beginning at 65; one dose (regardless of previous PCV13/PPSV23 immunization; see CDC; serial administration with PCV13 may be indicated) 19-58; one or two doses, give as necessary based upon risk and past immunization history; 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, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield 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. 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)[www.cdc.gov] ****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)[www.ahrq.gov/clinic/uspstfix.htm] A Implementation date: May 2015 B Implementation date: June 2015 C Implementation date: August 2015 D Implementation date: September 2015 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); Eighth Joint National Committee (JNC 8); Institute of Medicine (IOM); U.S. Food and Drug Administration (FDA) v2015.2 Revised 3/11/2015

SeniorBlue HMO and SeniorBlue PPO Health Maintenance Guidelines* SERVICE Initial Preventive Physical Examination (IPPE) ( Welcome To Medicare Preventive Visit) includes medical/social history review, depression screen, functional ability and safety screen, height, weight, BMI, blood pressure, visual acuity screen, end-of-life planning, optional screening EKG, and education, counseling, and referral for other Medicarecovered preventive services as appropriate Annual Wellness Visit (AWV) Obesity Screening/Counseling Depression Screening Lung Cancer 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 (HDL) Low Density Lipoprotein (LDL) 2 Triglycerides Lipid panel Fasting Plasma Glucose and/or Post-glucose Challenge Test 1 HIV Test Hepatitis C Test 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: http://www.cms.hhs.gov/mlnproducts/downloads/mps_qri_ippe001a.pdf Medicare s quick reference chart describing all preventive services, including applicable medical codes, is available: http://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/mps_quickreferencechart_1.pdf Once per year; must begin no sooner than 12 months after above exam (IPPE) If BMI > 30, one face-to-face or group 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 is covered One screening per year One counseling/shared decision-making visit; subsequent annual visits as needed 15 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 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 11 for infection; for pregnant Members, up to three tests per pregnancy One-time screening test for: Members born from 1945 through 1965; Members who received a blood transfusion before 1992; Members with a current or past history of illicit injection drug use One repeat screening test every year for Members at continued high risk 14

STI Testing 10 SeniorBlue HMO and SeniorBlue PPO Health Maintenance Guidelines* One screening test every year for men at increased risk 11 for syphilis One screening test every year for non-pregnant women at increased risk 11 for Chlamydia, gonorrhea and syphilis Once per year for male Members age 50 and older Digital Rectal Exam with Prostate Specific Antigen Test Clinical Breast Exam; Pelvic Exam with Pap Smear Glaucoma Exam One screening every year for Members at high risk 3 Routine Hearing Test 13 Once per year Once every 24 months for all female Members not at high risk (every 12 months if at high risk) 12 One-time screening for abdominal aortic aneurysm (AAA) for male Members Abdominal Ultrasound ages 65-75 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 35-39 Bone Mass Measurement Fecal Occult Blood Test 5 Flexible Sigmoidoscopy Colonoscopy Barium Enema X-ray 7 Low Dose Chest CT Scan (LDCT) IMMUNIZATIONS One screening every year for female Members age 40 and older One screening test every 2 years for high-risk 4 Members; more frequently if medically necessary Once per year for Members age 50 and older 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) 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) 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) Once per year for Members ages 55-77 who have no signs/symptoms of lung cancer, have a tobacco smoking history of at least 30 pack-years and are current smokers or have quit smoking within the last 15 years 15 RECOMMENDED AGES/FREQUENCY Influenza (Flu) [includes H1N1] Once per year (during flu season); additional flu shots if medically necessary Pneumococcal Vaccines (PCV13/PPSV23) One vaccine to all Members who have never received a pneumococcal vaccine A different, second vaccine should be given one year after the first vaccine 8 Hepatitis B (HBV) Once (series) for Members at medium or high 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. SeniorBlue PPO is offered by Capital Advantage Insurance Company, a Medicare Advantage organization with a Medicare contract. SeniorBlue HMO is offered by Keystone Health Plan Central, a Medicare Advantage organization with a Medicare contract. Enrollment in SeniorBlue PPO and SeniorBlue HMO is dependent on contract renewal. Dental and vision benefits are issued by Capital Advantage Assurance Company, a subsidiary of Capital BlueCross. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

SeniorBlue HMO and SeniorBlue PPO Health Maintenance Guidelines* * 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. 1 2 3 4 5 6 7 8 9 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. This intervention is 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. 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. According to current guidelines set forth by the Centers for Disease Control and Prevention (CDC) [www.cdc.gov], PCV13 is intended to be the initial vaccine and PPSV23 the second vaccine. However, prior pneumococcal vaccination history should be taken into consideration, as the reverse order may sometimes be justified. Receiving multiple vaccinations of the same vaccine type is not generally recommended. Capital BlueCross considers Members to be high risk in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC) [www.cdc.gov] 10 Covered screenings are for Chlamydia, gonorrhea, syphilis and/or Hepatitis B. Recommendations for screening of pregnant women are too detailed for inclusion here refer to Centers for Medicare & Medicaid Services (CMS) [www.cms.gov] 11 Increased risk criteria are based upon US Preventive Services Task Force (USPSTF) guidelines and include any Medicare beneficiary who asks for the testing [http://www.ahrq.gov/clinic/uspstfix.htm] 12 High-risk criteria are: women with a high risk for developing cervical or vaginal cancer or those of childbearing age with an abnormal Pap test within past 3 years. 13 This intervention is provided in excess of traditional Medicare Part B coverage but it is only a covered benefit for SeniorBlue HMO Options 1 and 2 as well as for SeniorBlue PPO Option 1. 14 Continued high-risk: Members who have had continued illicit injection drug use since the prior negative screening test. 15 Initial/subsequent lung cancer screening visits and written orders for eligible LDCT scans require certain medical record elements, which are too detailed for inclusion here refer to Centers for Medicare & Medicaid Services (CMS) [www.cms.gov]

SeniorBlue HMO and SeniorBlue PPO Health Maintenance Guidelines* Reference Sources: Centers for Medicare & Medicaid Services; Novitas Solutions; Centers for Disease Control and Prevention (CDC) v2015.2 Revised: 3/11/2015