What You Need to Know About. The Affordable Care Act: Preventive Services

What You Need to Know About The Affordable Care Act: Preventive Services 2015 Edition Published by Provider Relations and Education Your Partners in Outstanding Quality, Satisfaction and Service Revision: October 2015

This document provides a detailed outline of the services approved as preventive under the Affordable Care Act (ACA) for non-grandfathered plans. What the Law Requires The ACA, or Health Care Reform law, requires non-grandfathered plans to cover certain preventive care services at no cost sharing when members use in-network providers. The United States Preventive Services Task Force (USPSTF) A and B recommendations describe these recommended preventive services. We based immunization guidelines on those from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA) guidelines, including the American Academy of Bright Futures recommendations. These are independent organizations that provide health information on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan. Who Does It Impact The preventive services provisions of the law apply to non-grandfathered health plans. These include both individual health plans and employer-sponsored (group) health plans. A non-grandfathered plan is one that took effect after the government enacted the law on March 23, 2010. A grandfathered health plan is one that was in effect before this date. A plan remains grandfathered as long as it does not significantly reduce benefits or increase out-of-pocket spending above what it was when the government enacted the new law. When Does It Take Effect The preventive services provision took effect for non-grandfathered plans for plan years on or after September 23, 2010. Coverage for additional women s preventive services took effect for plan years on or after August 1, 2012. As services are added or updated, health plans must begin to provide coverage consistent with the recommendation. They must take effect in the first plan or policy year that begins on or after one year after the recommendation went into effect. 2

Providing Services and Billing There may be times when a patient who receives recommended preventive care still must pay an out-of-pocket amount for the associated office visit. For instance, how you bill and code the preventive service either separately from the office visit or with the office visit can dictate whether there is a patient liability or not. The primary purpose of the office visit will also determine if there will be an out-of-pocket amount associated with the care. If you bill the preventive service separately from the office visit, we may require the patient to pay the usual cost-sharing (deductible, coinsurance or copayment) amount for the office visit but not the recommended preventive service. This may occur regardless of the primary purpose for the office visit. If you include the recommended preventive care service with the office visit, then the primary purpose of the office visit must be preventive in nature. If the primary purpose of the office visit is to get the recommended preventive care service, the patient does not have to pay for the office visit or preventive care service. For example, if a child receives a wellchild exam and immunizations and the primary purpose of the visit was preventive care, the patient will not have any liability for the immunizations or exam. If the primary purpose of the office visit is for something other than the recommended preventive care service, you may charge the patient the usual cost-sharing amount (deductible, copayment or coinsurance) for the office visit. For example, if a child receives an exam for a complaint (sore throat, cough, etc.) and also receives immunizations, there may be an out-of-pocket expense for the exam but not the immunizations. If you provide services that aren t included in this guide, be sure to bill the services with a diagnosis that s appropriate for the exam or service. Otherwise, we may not cover the services. Services are typically included as part of a normal wellness visit. Use the appropriate office visit code. We consider evaluation and management codes 99381-99397 to be preventive. Codes 99401-99404, when used to designate a preventive service, must have the applicable wellness or preventive diagnosis code as the primary reason for the visit. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), you can bill the service with modifier -33. Please note use of the 33 modifier with specific surgical codes will help identify the procedure as preventive. For More Information This document provides an overview of these services. You should also visit the appropriate websites (listed throughout this document) for more details. You can also visit www.healthcare.gov for more information. Please refer to the appropriate medical policies on our websites for additional information and criteria: CAM 089 Preventive Services for Non-Grandfathered (PPACA) Plans: USPSTF Recommended Services CAM 094 Women s Preventive Services CAM 109 Preventive Services for Non-Grandfathered (PPACA) Plans: Immunizations If you have questions, contact Provider Education at 803-264-4730 or email Provider.Education@bcbssc.com. 3

Preventive Services USPSTF A and B Recommendations To read more about these services, please visit www.uspreventiveservicestaskforce.org/browserec/index/browse-recommendations. (This link leads to a third party site. That organization is solely responsible for the contents and privacy policies on its site.) Please keep in mind that services may be added to this list or changed. When that occurs, health plans must begin to provide coverage consistent with the recommendation in the first plan or policy year that begins on or after one year after the recommendation went into effect. Recently added or updated services are in the footnotes with their effective dates. Test/Service Patient Criteria Other Information Abdominal aortic aneurysm (AAA) 1 Alcohol misuse counseling and/or Aspirin to prevent cardiovascular disease Aspirin to prevent preeclampsia 2 Bacteriuria One time for men ages 65-75 who have ever smoked. Adults ages 18 years or older for alcohol misuse. Men ages 45 to 79 years. Women ages 55 to 79 years. Pregnant women after 12 weeks of gestation Pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later. For persons engaged in risky or hazardous drinking, provide brief behavioral counseling interventions to reduce alcohol misuse. Recommend when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Recommend a low-dose aspirin (81 mg/d) for women who are at high risk for preeclampsia. G0389 99408 G0396 G0443 87086 V15.82 V81.2 ICD-9 Z136 Z87891 V79.1 Z1389 V22.0-V22.2 V23.0-V23.9 ICD-10 O0900-O0933 Z331 Z34-Z3493 4

Test/Service Patient Criteria Other Information Use one of several tools to identify if there is a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). ICD-9 ICD-10 BRCA testing, risk assessment genetic counseling/testing Women who have family members with breast, ovarian, tubal or peritoneal cancer. Examples of tools include, but are not limited, to: Ontario Family Health Assessment tool Manchester Scoring System Referral Screening tool Pedigree Assessment tool 99385-99387 99395-99397 81211-81217 96040 S0265 V16.3 V16.40 V16.41 V26.33 Z315 Z803 Z8041 Z8049 Breast cancer, preventive medication Breast cancer (mammography) Breastfeeding counseling Women who are at increased risk for breast cancer and are at low risk for adverse medication effects. Women with or without clinical breast examination, every one - two years for women ages 40 and older. During pregnancy and after birth to promote and support breastfeeding. Women with positive results should receive genetic counseling. If indicated after counseling, provide BRCA testing. Educate women about medications to reduce their risk. Clinicians should offer to prescribe riskreducing medications, such as tamoxifen or raloxifene. Examples of tools include, but are not limited, to: Ontario Family Health Assessment tool Manchester Scoring System Referral Screening tool Pedigree Assessment tool Our medical policy, CAM 046, also addresses breast pumps. It indicates we allow these two breast pumps for members who qualify with no cost sharing: Ameda Purely Yours electric pump Ameda One Hand Manual pump 99401-99404 77052 77057 G0202 99401 99402 V16.3 V84.01 V76.10 V76.11 V76.12 V22.0- V24.2 V24.1 Z1501 Z803 Z1231 Z1239 O0900-O0993 Z331 Z34-Z3493 Z390-Z392 5

Test/Service Patient Criteria Other Information ICD-9 ICD-10 Cervical cancer Women ages 21 to 65 years. Women ages 30 to 65 years who want to lengthen the interval. Cytology (Pap smear) every three years. Screening with a combination of cytology and human papillomavirus (HPV) testing every five years. 87623-87625 88141-88154 88164-88167 88174-88175 G0101 G0123-G0124 V72.3 V72.31 V72.32 V76.2 Z01411 Z01419 Z0142 Z124 Chlamydia infection (women and adolescents 3 ) All sexually active nonpregnant young women ages 24 and younger. Also for older, non-pregnant women who are at increased risk. All pregnant women ages 24 and younger. Also for older, pregnant women who are at increased risk. 87490 87491 V73.88 V73.98 Z118 Colorectal cancer * Dental caries (preschool children 4 ) Depression (adolescents) Depression (adults) Adults, beginning at age 50 and continuing until age 75. All infants and children starting at the age of primary tooth eruption. Children at age 6 months whose water supply is fluoride deficient. Adolescents ages 12-18. Adults. Screening methods include: Fecal occult blood testing Sigmoidoscopy Colonoscopy The risks and benefits of these methods vary. Apply fluoride varnish to the primary teeth in primary care practices. Primary care clinicians should prescribe oral fluoride supplementation. Screen for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal) and follow up. Screen when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow up. 00810 45330-45349 45378-45392 82270 82274 G0104 G0106 G0122 G0328 99188 D1208 99420 G0444 99420 G0444 V76.41 V76.51 Z1211 Z1212 V79.0 Z1389 V79.0 Z1389 6

Test/Service Patient Criteria Other Information Diabetes mellitus Type 2 (adults) Diabetes mellitus (pregnant women 5 ) Fall prevention (communitydwelling, older adults) Folic acid, prevention of neural tube defects Gonorrhea prophylaxis Gonorrhea 6 Hearing loss Hepatitis B virus (HBV) (pregnant) Asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Asymptomatic pregnant women, 24-28 weeks of gestation and at the first prenatal visit for pregnant women identified as high risk for diabetes. Community-dwelling adults ages 65 or older who are at increased risk for falls. All women planning or capable of pregnancy. Newborns. All sexually active women, including those who are pregnant. Newborn infants (less than 1 month of age). Pregnant women at their first prenatal visit. Provide exercise or physical therapy and vitamin D supplementation to prevent falls. Recommend they take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Not routinely covered for all women capable of pregnancy. Provide prophylactic ocular topical medication against ophthalmia neonatorum. Screen for gonorrhea infection if they are at increased risk for infection (i.e., if young or have other individual or population risk factors). After the 4th month, if there are positive responses to risk questions, refer the infant for diagnostic audiologic assessment. 82947 82948 82947 82948 82950 97001 97002 97110 97116 97750 A9152 87590 87591 87850 92558 92586 80055 87340 ICD-9 V77.1 Z131 V22.0-V22.2 V23.0-V23.9 V77.1 V15.88 V65.41 V65.43 ICD-10 O0900-O0993 Z131 Z331 Z34-Z3493 Z390-Z392 Z7189 Z9181 V20.2 Z00129 V70.0 V72.3 V72.31 V22.0-V24.2 V30-V39 V22.0-V22.2 V23.0-V23.9 V28.9 O0900-O0993 Z0000 Z01411 Z01419 Z331 Z34-Z3493 Z390-Z392 Z380-Z388 O0900-O0993 Z331 Z34-Z3493 Z36 7

Test/Service Patient Criteria Other Information Hepatitis B virus (HBV) (non-pregnant adolescents and adults 7 ) Hepatitis C virus (HCV) High blood pressure HIV counseling and Non-pregnant adolescents and adults at high risk for infection. Persons at high risk for infection. Offer a one-time for HCV infection to adults born between 1945 and 1965. Adults ages 18 and older. Adolescents and adults ages 15-65 years. Younger adolescents and older adults who are at increased risk. All pregnant women, including those who present in labor who are untested and whose HIV status is unknown. In addition, CDC guidance for high risk for infection includes: Persons born in geographic regions with HBsAg prevalence of >2% US-born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of >8% Injection drug users Men who have sex with men Persons with elevated ALT/AST of unknown etiology Persons with selected medical conditions who require immunosuppressive therapy Pregnant women Infants born to HBsAg-positive mothers Household contacts and sex partners of HBV-infected persons Persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health care worker) Persons infected with human immunodeficiency virus (HIV) 80055 87340 86803-86804 G0472 99385-99387 99395-99397 86703 87389 87390 G0432 G0433 ICD-9 V81.1 Z136 V01.79 V22.0- V24.2 ICD-10 O0900- O0993 Z206 Z20828 Z331 Z34-Z3493 Z390-Z392 8

Test/Service Patient Criteria Other Information Hypothyroidism Intimate partner violence /counseling of women, annually Iron deficiency anemia Iron supplementation Lipid (cholesterol) Lung cancer, adults ICD-9 Newborns. 84443 V77.0 Z1329 Women of childbearing age. Asymptomatic pregnant women. Asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia. Men ages 35 and older for lipid disorders. Men ages 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Women ages 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Women ages 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Adults ages 55-80 years who have a 30 pack-peryear smoking history and currently smoke or have quit within the past 15 years. Screen for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse. Screen annually for lung cancer with low-dose computer tomography. You should discontinue once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 99401 99402 and 99404 require review of records. 80055 85013 85014 85018 V61.11 Z6911 V22.0- V23.9 V20.2 Z0129 ICD-10 O0900-O0993 Z331 Z34-Z3493 80061 V77.91 Z13220 71250 (with modifier 52) S8032 (effective 10/01/2014) V76.0 Z122 9

Test/Service Patient Criteria Other Information Nutrition (dietary) counseling, adults 8 Obesity in adults and children ages 6 or older, and counseling Osteoporosis Phenylketonuria (PKU) Rh incompatibility Sexually transmitted infections (STIs), behavioral counseling to prevent 9 Sickle cell disease Skin cancer counseling Syphilis Adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors. Effective June 2012: All adults with a body mass index (BMI) of 30 kg/m2 or higher. Women ages 65 and older and younger women whose fracture risk is equal to or greater than that of a 65- year-old white woman who has no additional risk factors. Offer or refer them to intensive behavior counseling interventions to promote a healthy diet and physical activity for CVD prevention. Offer or refer patients to intensive, multicomponent behavioral interventions. 97802-97804 G0270 S9470 99401 99402 G0447 ICD-9 V65.3 Z713 V77.8 Z1389 77080 V82.81 Z13820 All newborns. 84030 V77.3 Z13228 All pregnant women during their first visit for pregnancy-related care. All unsensitized Rh (D)- negative women at 24-28 weeks gestation, test for repeated Rh (D) antibodies unless the biological father is known to be Rh (D)-negative. All sexually active adolescents and adults at increased risk for STIs. Newborns. Children, adolescents and young adults ages 10 to 24 who have fair skin. All persons at increased risk for syphilis infection. All pregnant women. Offer high-intensity behavioral counseling to prevent STIs. Counsel about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. 80055 86901 99401 99402 83020 83021 V22.0-V23.9 V65.44 V65.45 V69.2 V30-V30.9 V78.2 ICD-10 O0900-O0993 Z331 Z34-Z3493 Z717 Z7189 Z7251 Z38-Z38.8 99401 V65.43 Z7189 80055 86592 86780 V22.0-V23.9 V69.2 V74.5 O0900-O0993 Z113 Z331 Z34-Z3493 Z7251 10

Test/Service Patient Criteria Other Information Tobacco use,, counseling and interventions Visual impairment Well woman preventive care visit All adults. All pregnant women. School-aged children. All children between the ages of 3 and 5. Recommended annually to obtain the recommended preventive services that are age and developmentally appropriate. All women, one annually, as age and developmentally appropriate. Ask about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Ask about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. Provide interventions, including education or brief counseling, to prevent initiation of tobacco use. Visual by a non-eye care professional, at least once, to detect the presence of amblyopia or its risk factors. The procedure filed will be used to determine no cost share issues, not the diagnosis filed. 99406 99407 99173 99174 S0610 S0612 S0613 99384 99385 99386 99387 99394 99395 99396 99397 G0438 G0439 S5190 ICD-9 305.1 649.01-649.04 V15.82 V15.89 ICD-10 F17200 O99300- O99335 Z779 Z87891 Z9289 V80.2 Z135 V72.3 V72.31 *Use of the 33 modifier with specific surgical codes will help identify the procedure as preventive. Coverage at no cost share for these footnoted services take effect for plan or policy years that begin on or after these dates: 1. 2. 3. 4. 5. June 30, 2015 September 30, 2015 September 30, 2015 May 31, 2015 January 14, 2015 6. 7. 8. 9. September 30, 2015 May 31, 2015 August 31, 2015 September 30, 2015 11

Contraception The ACA also addresses coverage for contraceptives, including Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt religious employers. NOTE: We will use the procedure filed to determine no cost-share issues, not the diagnosis filed. ICD-9 Procedures ICD-9 ICD-10 11976 11980 11981 11982 11983 57170 58300 58301 58340 58565 58600 58605 58611 58615 58671 58700 A4261 A4264 A4266 A4268 A4269 J1050 J7300 J7302 J7303 J7304 J7306 J7307 S4981 S4989 S4993 66.21 66.22 66.29 66.31 66.32 66.39 66.51 66.52 66.92 69.7 97.71 V15.7 V25.01 V25.02 V25.03 V25.04 V25.09 V25.11 V25.12 V25.13 V25.2 V25.40 V25.41 V25.42 V25.43 V25.49 V25.5 V25.8 V25.9 V26.41 V26.49 V26.51 V45.51 V45.52 V45.59 996.32 Z920 Z30018 Z30012 Z3009 ZZ3002 Z30430 Z30432 Z302 Z3040 Z3041 Z30431 Z3049 Z308 Z309 Z3161 Z3169 Z9851 Z975 T8339XA 12

Immunizations We consider these immunizations MEDICALLY NECESSARY when given in accordance with ACIP guidelines: We consider an immunization NOT MEDICALLY NECESSARY if it does not meet Vaccine Policy requirements for FDA labeling (including age and/or gender limitations) and if it does not have definitive ACIP recommendations published in the CDC s Morbidity and Mortality Weekly Report (MMWR). Immunization Category Immunization Administration Preventive when included as part of a preventive immunization 90460 90461 90471 90472 90473 90474 Description Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Age Group G0008 Administration of influenza virus vaccine G0009 Administration of pneumococcal vaccine G0010 Administration of hepatitis B vaccine Diphtheria 90719 Diphtheria toxoid, for Diphtheria and tetanus (DT) Diphtheria, tetanus toxoids, acellular pertussis and polio inactive (DTap-IPV) Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza B, and polio inactive (DTap- IPV/Hib) 90702 90696 90698 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years of age, for Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated polio virus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenzae Type b and inactivated polio virus vaccine (DTaP IPV/Hib), for Benefit/ Age Limit 13

Immunization Category Diphtheria, tetanus, acellular pertussis (DTap) Diptheria, tetanus and acellular pertussis and Haemophilus influenza B (DTaP-Hib) Diptheria, tetanus and acellular pertussis, hep B and polio inactive (DTaP-HepB-IPV) Diptheria, tetanus and whole pertussis and Haemophilus influenza B (DTwP-Hib) Haemophilus influenza b (Hib) Hepatitis A Hepatitis B 90700 90721 90723 90720 90645 90646 90647 90648 90632 90633 90634 90636 90740 90743 90744 90746 90747 90748 Description Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years of age, for Diphtheria, tetanus toxoids and acellular pertussis vaccine and Haemophilus influenza b vaccine (DTaP/Hib), for Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B and inactivated polio virus vaccine (DTaP- HepB-IPV), for Diphtheria, tetanus toxoids and whole cell pertussis vaccine and Haemophilus influenzae b vaccine (DTwP- Hib), for Hemophilus influenza b vaccine (Hib), HbOC conjugate (four-dose schedule), for Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, three-dose schedule, for Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, four-dose schedule, for Hepatitis A vaccine (HepA), adult dosage, for Hepatitis A vaccine (HepA), pediatric/adolescent dosage-two-dose schedule, for Hepatitis A vaccine (HepA), pediatric/adolescent dosage-three dose schedule, for Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, three dose schedule, for Hepatitis B vaccine (HepB), adolescent, two dose schedule, for Hepatitis B vaccine (HepB), pediatric/adolescent dosage, three dose schedule, for Hepatitis B vaccine (HepB), adult dosage, three dose schedule, for Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, four dose schedule, for Hepatitis B and Haemophilus influenza b vaccine (Hib- HepB), for Age Group Adult Adult (adolescent only) Adult Benefit/ Age Limit Ages 0-6 years. Ends on 7th birthday. 14

Immunization Category Human Papilloma Virus (HPV) Measles, Mumps, Rubella (MMR) combination or individual Meningococcal Pneumococcal conjugate Pneumococcal polysaccharide (PPSV23) 90649 90650 Description Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (HPV4), three-dose schedule, for intramuscular use Human Papilloma virus vaccine, types 16, 18, bivalent (HPV2), three-dose schedule, for Age Group 90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), three-dose schedule, for 90704 Mumps virus vaccine, live, for subcutaneous use 90705 Measles virus vaccine, live, for subcutaneous use 90706 Rubella virus vaccine, live, for subcutaneous use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use 90708 Measles and rubella virus vaccine, live, for subcutaneous use 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Meningococcal recombinant protein and outer membrane 90620 vesicle vaccine, Serogroup B, two-dose schedule, for 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B, three-dose schedule, for Meningococcal conjugate vaccine, serogroups C & Y and 90644 Haemophilus influenzae b vaccine (Hib-MenCY), four-dose schedule, when administered to children 2-15 months of age, for 90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y, W- 135, quadrivalent (MPSV4) for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W- 135, quadrivalent (MenACWY), for 90669 90670 S0195 90732 Polio (IPV) 90713 Pneumococcal conjugate vaccine, 7 valent (PCV7), for Pneumococcal conjugate vaccine, 13 valent (PCV13), for Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not previously received the vaccine Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years of age or older, for subcutaneous or Poliovirus vaccine, inactivated (IPV), for subcutaneous or Benefit/ Age Limit Ages 9-26 years. Ends on 27th birthday. Females, ages 9-26 years. Ends on 27th birthday. This vaccine is not covered for males. Ages 9-26 years. Ends on 27th birthday. Age 10 and up. Age 10 and up. Age 0-5 years. Ends on 6th birthday. 15

Immunization Category 90680 Description Rotavirus vaccine, pentavalent (RV5), three-dose schedule, live, for oral use Age Group Benefit/ Age Limit Do not begin series in infants older than age 14 weeks 6 days. Rotavirus Seasonal Influenza ( flu ) Note: Additional new seasonal flu immunization codes that are recently FDAapproved, but are not listed here, may be eligible for preventive benefits as of the FDA approval date. 90681 90630 90653 90654 90655 90656 90657 90658 90660 90661 90662 90664 90666 90667 90668 90672 Rotavirus vaccine, human, attenuated (RV1), twodose schedule, live, for oral use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age, for Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for Influenza virus vaccine, trivalent(iiv3), split virus, when administered to children 6-35 months of age, for Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older, for Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Influenza virus vaccine (cciiv3), derived from cell cultures, subunit, preservative and antibiotic free, for Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for Influenza virus vaccine, live (LAIV), pandemic formulation, for intranasal use Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for Influenza virus vaccine (IIV), pandemic formulation, split virus, for Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Adult Adult Adult Intervals between doses may be as short as four weeks. If prior vaccination included use of different or unknown brand(s), you should give a total of three doses. 18 years 64 years. Ends on 65th birthday. Ages 2 49 years. Ends on 50th birthday. Ages 18 years and up. Ages 65 years and up. Ages 2 49 years. Ends on 50th birthday. Ages 2 49 years. Ends on 50th birthday. 16

Immunization Category Seasonal Influenza ( flu ) Note: Additional new seasonal flu immunization codes that are recently FDA-approved, but are not listed here, may be eligible for preventive benefits as of the FDA approval date. 90673 90685 90686 90687 90688 Q2034 Q2035 Q2036 Q2037 Q2038 Q2039 Description Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age, for Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older, for Influenza virus vaccine, split virus, for (Agriflu) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (AFLURIA) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (FLULAVAL) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (FLUVIRIN) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (Fluzone) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (not otherwise specified) Age Group Adult Adult Tentanus 90703 Tetanus toxoid adsorbed, for Tetanus and diphtheria toxoids adsorbed (Td), Tetanus and preservative free, when administered to 90714 diphtheria (Td) individuals 7 years of age or older, for Tetanus, diphtheria toxoids and acellular pertussis (Tdap) Varicella (VAR) ( chicken pox ) Zoster/Shingles (HZV) 90715 90716 90736 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years of age or older, for Varicella virus vaccine (VAR), live, for subcutaneous use Zoster (shingles) vaccine (HZV), live, for subcutaneous injection Adult Benefit/ Age Limit Ages 18 49 years. Ends on 50th birthday. Ages 18 years and up. Age 50 years and up. 17

October 2015 IMPORTANT NOTICE This document is provided for informational purposes only and does not constitute legal advice or legal opinions. BlueCross BlueShield of South Carolina makes no representations regarding the accuracy or legal effect of the information contained herein, and disclaims any warranty of any kind related to it. This document may be based on internal interpretations of Health Care Reform legislation, is subject to change without notice, and is not a substitute for legal advice from your lawyers. 18