An Independent Licensee of the Blue Cross and Blue Shield Association Preventive Care Services The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that Blue Cross and Blue Shield of Alabama has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act (healthcare reform). Some or all of the contraceptives Methods or prescription drugs listed may not be covered under the plan because of the employer s religious beliefs. To find out if contraceptives methods and prescriptions drugs are excluded, please contact Customer Service for additional information. **Services are still subject to Medical Management Criteria.** Blue represents coding updates. Description ICD9 Code Prior to 10/1/15 ICD10 Code Effective 10/1/15 Notes Abdominal Aortic Aneurysm, Screening Males only (with any history of smoking) Ages 65-75 years One in a lifetime Alcohol Misuse Screening and Behavioral Counseling Interventions One each calendar year (as needed) G0389 with V81.2, V15.82, or 305.1 99408 with V79.1, or 305.00-305.03 1/1/12 add G0442 and G0443 G0389 with Z13.6, Z72.0, Z87.891, or F17.200- F17.219, F17.290-F17.299 99408 with Z13.89, or F10.10, F10.120, F10.129 1/1/12 add G0442 and G0443 age restriction set up at 18-99 years 6/30/12 cancel 99408 6/30/12 cancel 99408 Aspirin for the Prevention of Cardiovascular Disease Effective 10/01/10-06/30/16 men ages 45-79 years women ages 55-79 years Once every 5 calendar years 99401, 99386, 99387, 99396, or 99397 with V65.8 1/1/12 add G0446 99401, 99386, 99387, 99396, or 99397 with Z13.6 or Z76.89 1/1/12 add G0446 age restriction set up at 45-99 years and 55-99 years Effective 07/01/16 Men ages 50-59 years Women ages 13-59 years Once every 5 calendar years Asymptomatic Bacteriuria in Pregnant Women, Screening 87081, 87084, 87086, or 87088 with V22.0 - V23.0, 640.00-659.93, V91.00-V91.03, V91.09-V91.12, V91.19-V91.22, 99401, 99386, 99387, 99396, or 99397 with Z13.6 or Z76.89 1/1/12 add G0446 87081, 87084, 87086, or 87088 with O09.00-O09.03, O09.40 O09.529, O10.011 O15.03, O15.2-O21.9, O23.00- Effective 07/01/16, new age ranges will apply. Impacted members will be grandfathered to continue receiving aspirin 81mg until 06/30/17 and will receive a letter; there will be NO disruption to impacted members 07/01/16. Letters will also be sent to impacted members just prior to 07/01/17 reminding that this product will no longer be a covered preventive service unless age meets new range requirement.
Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Females only One session in a lifetime V91.29, V91.90-V91.92, V91.99, or V81.5 96040, or 99401-99404 with V16.3, V16.41, V26.33, or V84.01 Effective 2/20/13 81211, 81212, 81213, 81214, 81215, 81216 and 81217 9/1/15 add V10.3 or V10.43 O26.43, O26.611-O26.93, O29.011-O30.019, O30.031- O35.6XX9, O35.8XX0- O36.73X9, O36.8120-O36.8199, O36.8910-O42.019, O42.10- O42.119, O42.90-O42.919, O43.011-O43.119, O43.191- O43.199, O43.811-O61.9, O67.0-O68, O75.2, O75.3, O75.5, O75.82-O77.0, O80, O86.11, O86.13-O86.29, O90.5- O90.89, O98.011-O9A.53, Z13.89, Z33.1, or Z34.00-Z34.93 96040, or 99401-99404 with Z15.01, Z31.5, Z80.3, or Z80.41 Effective 2/20/13-12/31/15 81211, 81212, 81213, 81214, 81215, 81216 and 81217 9/1/15 add Z85.3 or Z85.43 combined with chemo prevention of breast cancer Effective 9/1/15 codes V10.3, V10.43 (ICD-9) and Z85.3 and Z85.43 (ICD-10) added based on ad hoc review based on FAQ and guidance published in Federal Register July 14, 2015. Effective 1/1/16 81211, 81212, 81213, 81214, 81215, 81216, and 81217 OR 81162 and 81212* For Mutation testing: This new code (81162) is a combination of the other codes (except 81212), therefore, the other codes (81211, 81213, 81214, 81215, 81216 and 81217) should not be allowed beyond the once in a lifetime max once 81162 has been done. 81212 is a separate code that may be done for a specific risk group in addition to the other codes (once in a lifetime max as well). Therefore, if possible, set up processing to differentiate between the two groups as follows: 81211, 81213, 81214, 81215, 81216, 81217 and 81212 OR Revised 11/10/2016 HDM Page 2
81162 and 81212 Breast Cancer Prevention Medication Effective 10/1/2014 Pharmacy only Females only age 35 and older To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. Breastfeeding, Behavioral Interventions to Promote Females only Twice per calendar year 99401 must have modifier TH and V22.0-V23.9 or V24.1 99401 must have modifier TH and O09.00-O09.93, O09.A0-O09.A3, O36.80X0- O36.80X9, Z33.1, Z34.00- Z34.93 or Z39.1 *Also see additional benefits in Women s Preventive section at the bottom of this document Cervical Cancer, Screening (PAP Smear) also known as Cervical Dysplasia Screening One each calendar year No age limitations Chemoprevention of breast cancer Females only One in a lifetime 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153,88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with 99401, or 99402 with code V16.3 or V84.01 10/1/16 add Z33.3 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153,88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with 99401, or 99402 with code Z80.3 or Z15.01 combined with BRCA benefit above Chlamydia Infection, Screening Females age 15-21 One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with except V74.5 (see STI Screening) Or 87800, 86631, 86632 with V73.88 or V73.98 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with except Z11.3 (see STI Screening) Or 87800, 86631, 86632 with Z11.8 Chlamydia split due to V74.5 overlapping with STI Screening preventing visit maximums from applying correctly Females age 22-24 87110, 87270, 87320, 87490, 87110, 87270, 87320, 87490, Revised 11/10/2016 HDM Page 3
One each calendar year Effective 12/1/2014 Females age 15-21 One each calendar year 87491, 87492, or 87810 with Or 87800, 86631, 86632 with V73.88 or V73.98 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with except V74.5 (see STI Screening) Or 87800, 86631, 86632 with V73.88 or V73.98 87491, 87492, or 87810 with Or 87800, 86631, 86632 with Z11.8 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with except Z11.3 (see STI Screening) Or 87800, 86631, 86632 with Z11.8 Females age 22-99 One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with Or 87800, 86631, 86632 with V73.88 or V73.98 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with Or 87800, 86631, 86632 with Z11.8 Routine Cholesterol (Lipid Disorders in Adults), Screening Men age 35 years and older (20-35 at risk for CAD) Women age 45 years and older (20-45 at risk for CAD) One every 5 calendar year Colorectal Cancer, Screening 82465 or 83718 with routine Same as COL rider 82465 or 83718 with routine Same as COL rider Age restriction set up at 20-99 years Age restriction set up at 50-99 years Pre-Screening Consultation Effective 1/1/16 Once every 10 calendar years Ages 50-75 years Colonoscopy Once every 10 calendar years 99386 or 99387 with code Z12.11 OR 99396 or 99397 with code Z12.11 Colonoscopy G0121, G0105, G6019, G6020, 99386 or 99387 with code Z12.11 OR 99396 or 99397 with code Z12.11 OR S0285 with Z12.11 Colonoscopy G0121, G0105, G6019, G6020, Anesthesia Prior to 07/01/11 00810, 99143-99145, 99148-99150 with Revised 11/10/2016 HDM Page 4
Ages 50-75 years Includes outpatient facility services, physician services, and anesthesia. G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44401, 44402, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, 45392 or 45399. G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44932, 44393, 44394, 44401, 44402, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, 45392 or 45399. Effective 07/01/11-12/28/15 00810, 99143-99145, 99148-99150 covered when medical criteria is satisfied. (See Medical Policy # 470, Monitored Anesthesia Care) Effective 12/28/15 Refer to https://www.bcbsal.org/providers/pdfs/anesthe sia.pdf for Monitored Anesthesia Care Age restriction set up at 50-99 years **12/31/14 delete codes 44393, 44397, 45355, 45383, 45387 **1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025 **12/31/14 delete codes 44393, 44397, 45355, 45383, 45387 **1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025 **1/1/16 delete codes G6019, G6020, G6021, G6024, G6025 Age restriction set up at 50-99 years Age restriction set up at 50-99 years Bowel Prep Medications Effective 07/01/16 Ages 50-75 Bowel Prep Medications PEG-3350/NaCl/Na Bicarbon (NDC 10572030201) PEG-3350/NaCl/Na Bicarbon (NDC 10572040001) Gavilyte-N/Flavor Pack (NDC 43386005019) Trilyte (NDC 51525683104) PEG-3350/NaCl/Na Bicarbon (NDC 64380076921) (GPIs: 46992004302120, 46992004302130, 46992004302140 (MSC=Y) only) Per USPSTF recommendation - Clinical Considerations Patient Population under Consideration - These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with firstdegree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. Furthermore, when the screening test results in the of clinically significant colorectal Revised 11/10/2016 HDM Page 5
Anesthesia 00810,99143-99145,99148-99150 With Anesthesia 00810,99143-99145,99148-99150 With adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable. Sigmoidoscopy Ages 50-75 years Once every 3 calendar years Barium Enema Part of standard COL Ages 50-75 years Once every 5 calendar years Hemoccult Ages 50-75 years One each calendar year Congenital Hypothyroidism, Screening Newborns - ages 2-4 days Sigmoidoscopy G0104 or 45330 with routine Barium Enema G0106, G0120, G0122, or 74280 with Hemoccult G0107, G0328, G0394, 82270, 82272, or 82274 with routine 84436, 84437, 84439, or 84443 with V77.0 Sigmoidoscopy G0104 or 45330 with routine 1/1/16 add 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45340, 45341, 45342, 45347 Barium Enema G0106, G0120, G0122, or 74280 with Hemoccult G0107, G0328, G0394, 82270, 82272, or 82274 with routine 84436, 84437, 84439, or 84443 with Z13.29 Dental Caries in Children From Birth Through Age 5 Years, Prevention of Effective 6/1/2015 Birth 5 years Male and Females Maximum 4 per calendar year CPT 99188 with V07.31 CPT 99188 with Z41.8 10/1/16 delete Z41.8 10/1/16 add Z29.3 Dental Caries in Preschool Children, Prevention Depression, Screening Ages 12 years and older One each calendar year Effective 1/1/2015 Ages 11 years and older One each calendar year Included in preventive office visit 99401 with V79.0 1/1/12 add G0444 6/30/12 cancel 99401 Included in preventive office visit 99401 with Z13.89 1/1/12 add G0444 6/30/12 cancel 99401 Revised 11/10/2016 HDM Page 6
Developmental Screening Ages 9-30 months Four services during age range 96110 with 1/1/12 add G0451 96110 with 1/1/12 add G0451 Effective 1/1/2015 Ages 9-30 months Five services during age range Developmental Surveillance for Children Included as part of an office visit Included as part of an office visit Developmental/Behavioral Assessment Alcohol and Drug Ages 11-21 years One each calendar year G0396, H0001, or 99408 with V69.8 or V69.9 1/1/12 add G0442, G0443 6/30/12 cancel 99408 G0396, H0001, or 99408 with Z72.0, Z72.89, Z72.9, or Z73.9 1/1/12 add G0442, G0443 6/30/12 cancel 99408 Dyslipidemia Screening Ages 2-10 years: Once every 2 calendar years Ages 11-17 years: One each calendar year Ages 18 21 years: Once during age range Behavioral Counseling in Primary Care to Promote a Healthy Diet (Diet Counseling) Three hours each calendar year Ages 19 and older 80061 with V77.91 80061 with Z13.220 97802-97804, G0270 or G0271 with V65.3, 249.00-250.93, 648.00-648.04, 401.0-414.07, 414.10-414.9, 425.0-425.9, 428.0-428.9, 429.1-429.3, 429.9, 278.00, 278.01, 649.10-649.14, V85.30-V85.39, V85.41- V85.45, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07 or 366.41 97802-97804, G0270 or G0271 with Z71.3, A18.84, E08.00 E13.9, E66.01-E66.1, E66.8, E66.9, I10-I22.9, I16.0, I16.1, I16.9, I24.0-I25.9, I42.0- I43, I50.1- I50.9, I51.5-I51.7, I51.9, I52, N26.2, O24.011- O24.33, O24.811-O24.93, O99.210-O99.215, or Z68.30- Z68.45 Gonorrhea, Screening Female only ages 22-99 (Ages 11-21 included in STI screening) Two each calendar year 1/1/12 add G0446 87590, 87591, 87850, 87800 or 87801 with V74.5 1/1/12 add G0446 87590, 87591, 87850, 87800 or 87801 with Z11.3 Ages changed due to 11-21 already included in the STI Screening, again preventing visit maximums from applying correctly Gonorrhea, Prophylactic Medication, No code available - usually No code available - usually Revised 11/10/2016 HDM Page 7
Newborn Hematocrit or Hemoglobin Ages 4 months-10 years, no more than 3 tests. Ages 11-21 years--one each calendar year Hepatitis B Virus Infection in Pregnancy, Screening for Females (pregnant) One each calendar year administered as an ancillary charge while inpatient at time of delivery 85014 or 85018 with V78.0 87340 and V22.0- V23.9 administered as an ancillary charge while inpatient at time of delivery 85014 or 85018 with Z13.0 87340 and O09.00- O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z34.93 10/1/16 add Z33.3 Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults, Screening for Effective 6/1/2015 Ages 11-99 Females and Males One each CPT code per calendar year 86704, 86705, 86706, 87340 or 87341 with V08, V12.09, V12.29, V15.85, V45.11, V56.0, V58.11, V58.12, V61.49, V62.5, V87.46, V87.49. 070.41, 070.44, 070.51, 070.54, 070.70 or 070.71 86704, 86705, 86706, 87340 or 87341 with Z21, Z51.11, Z51.12, Z57.8, Z63.6, Z63.79, Z65.1, Z65.2, Z77.21, Z86.19, Z86.2, Z92.25, Z92.29, Z99.2, B17.10, B17.11, B18.2, B19.20 or B19.21 Hepatitis C Virus (HCV) Infection, Screening Once per lifetime screening for males and females Once per year* screening for males and females 86803 AND 86804 with: born 1945 through 1965 OR with dx code V18.3 (being born to an HCVinfected mother) OR for dx codes V87.49, V15.85, V45.11, V62.5 86803 AND 86804 with: born 1945 through 1965 OR with dx code Z83.2 (being born to an HCVinfected mother) OR for dx codes Z92.29, Z77.21, Z99.2, Z65.1, Z65.2, Z57.8 *For frequency once per year for risk groups if high risk behavior has ever occurred and person never screened previously, or high risk behavior has occurred since last screening (clinical consideration in study by USPSTF 60% of new HCV infections occur in persons who report injection drug use within the past 6 months ) 10/1/14 add G0472 10/1/14 add G0472 High Blood Pressure, Screening One each calendar year as needed. Ages 18 years and older Effective 11/1/2016 Office Blood Pressure Measurement: One each calendar year as needed. Ages 18 years and older Usually included as part of an office visit Usually included as part of an office visit Included as part of an office visit Revised 11/10/2016 HDM Page 8
Ambulatory Blood Pressure Monitoring: One per lifetime to confirm the of hypertension 93784 OR 93786, 93788, 93790 HIV, Screening Ages 11 years and older No frequency *Beginning August 1, 2012 for females beginning at age 10. Human Papillomavirus (HPV) Part of Standard PMD Ages 30-99 years Females only One every 3 calendar years 86701, 87535, 87534, 87390, 86703, G0432, G0433, or G0435 with V73.89 1/1/12 add 87389 1/1/15 add code 87806 87620, 87621, or 87622 with 12/31/14 delete 87620, 87621, 87622. 1/1/15 add 87623, 87624, or 87625 with 86701, 87535, 87534, 87390, 86703, G0432, G0433, or G0435 with Z11.4 1/1/12 add 87389 1/1/15 add code 87806 1/1/16 add G0475 87620, 87621, or 87622 with 12/31/14 delete 87620, 87621, 87622. 1/1/15 add 87623, 87624, or 87625 with 1/1/16 add G0476 Immunizations See Routine Immunizations Standard PMD Contracts on DORS See Routine Immunizations Standard PMD Contracts on DORS Inpatient Newborn Care Newborns Inpatient physician services only 99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a Inpatient physician services only 99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a Iron Deficiency Anemia, Prevention Pharmacy Benefit Pharmacy Benefit Iron Deficiency Anemia, Screening Females (pregnant) One each calendar year 85013, 85014, 85018, 85025, or 85027 with V22.0- V23.9 85013, 85014, 85018, 85025, or 85027 with O09.00- O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z34.93 10/1/16 add Z33.3 Revised 11/10/2016 HDM Page 9
Lead Screening Ages 6 months 6 years 3 tests during age range 83655 with V82.5 83655 with Z13.88 Lung Cancer, Screening with Low-Dose Computed Tomography Effective 1/1/2015 55-80 years old Male and Females One each calendar year 71250 or S8032 with V76.0 and V15.82 71250 or S8032 with Z12.2 and Z878.91 1/1/16 add G0297 10/1/16 Cancel S8032 Mammography and Digitization One baseline for females ages 35-39 years One annually for females age 40 and over G0202, G0204, G0206, G0236, 76085, 77051-77052, 77055, 77056, or 77057 with routine Effective 8/1/2012 add V16.3 and V76.11 as a high risk G0202, G0204, G0206, G0236, 76085, 77051-77052, 77055, 77056, or 77057 with routine Effective 8/1/2012-9/30/2015 add Z80.3 and Z12.31 as a high risk HCP did not list as covered we included in HCP so there would be no disruption of coverage Effective 10/1/2015 code Z12.31 is considered a routine Newborn Metabolic/Hemoglobin Screening Ages 0-2 months One test during age range Newborn Screening Panel Ages birth-31 days S3620 with no specific required 83788 with routine V77.3 83498 or 83788 with V77.99 83020 with routine V78.3 82261 with routine V77.99 83516 with routine V77.6 82776 with routine V77.4 86355 or 86359 with S3620 with no specific required 83788 with routine Z13.228 83498 or 83788 with Z13.21, Z13.228, Z13.29 83020 with routine Z13.0 82261 with routine Z13.21, Z13.228, Z13.29 83516 with routine Z13.228 82776 with routine Z13.228 86355 or 86359 with Revised 11/10/2016 HDM Page 10
V77.99 82760 with routine V77.4 82759 with routine V77.4 86359 with routine V77.99 Z13.21, Z13.228, Z13.29 82760 with routine Z13.228 82759 with routine Z13.228 86359 with routine Z13.21, Z13.228, Z13.29 Effective 1/1/16 Delete 83788 with routine Z13.228 Add 83789 with routine Z13.228 Obesity in Adults and Children Screening. Ages 6 years and older One per calendar year Oral Health Ages 6 months-6 years. 3 services during age range Osteoporosis in Postmenopausal Women, Screening 99401 with V77.8 1/1/12 add G0447 99401 with Z13.89 1/1/12 add G0447 99420 with V72.2 99420 with Z01.20 or Z01.21 10/31/15 remove Z01.20, Z01.21 11/1/15 add Z13.84 Effective 10/01/2010 01/31/2012 Ages 65 and older. 60 and older if at risk Females only Once every 4 calendar years (prior to 2/1/12) Effective 02/01/2012 Ages 65 and older. 65 and younger if at risk Females only Once every 2 calendar years 77080 with V82.81 77080 with V13.51, V13.52, V15.51, V17.81, V45.77, V82.81, V87.45, 305.1, 714.0-714.9, 720.0, 250.01, 250.03, 250.11, 250.13, 250.21, 250.23, 250.31, 250.33, 250.41, 250.43, 250.51, 250.53, 250.61, 250.63, 250.71, 250.73, 250.81, 250.83, 77080 with Z13.820 77080 with E05.00- E05.91, E10.10-E10.9, E23.6, E28.310-E28.39 E44.0-E46, E64.0, E89.40, E89.41, F10.20- F10.220, F10.229, F17.200- F17.299, K70.0-K70.40, K70.9, K73.0-K74.69, K75.4, K75.81, K76.0, K76.89, K76.9, K90.0- Age restriction set up at 0-99 years The U.S. Preventive Services Task Force did not make a frequency recommendation. The frequency follows the recommendation made by the American College of Obstetrics and Gynecology. Revised 11/10/2016 HDM Page 11
250.91, 250.93, 756.51, 758.6, 242.00-242.91, 256.2, 256.31, 256.39, 253.4, 263.0-263.9, V12.1, 579.0-579.9, 571.0-571.9, 303.00-303.93 or V11.3 K90.4, K90.89, K90.9, K91.2, M05.00-M06.9, M08.00-M08.99, M12.00-M12.09, M45.0-M45.9, M48.8X1-M48.8X9, Q78.0, Q96.0-Q96.9, Z13.820, Z71.41, Z72.0, Z82.62, Z86.39, Z87.310- Z87.312, Z87.81, Z90.721- Z90.79, or Z92.241 Over-the-Counter Pharmaceuticals Effective 08/01/2013 Aspirin Over the counter Effective 08/01/13-06/30/16 Men aged 45-79 years Women aged 55 79 years Effective 07/01/16 Men aged 50-59 years Women aged 13 59 years Contraceptive Methods Women only Generic only Fluoride Over-the-counter Ages 6 months 6 years Folic Acid Over-the-counter Women only Iron Supplements Over-the-counter Ages 6 months to 12 months Vitamin D Supplements Ages 65-99 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. 10/1/16 add K90.41 and K90.49 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. Phenylketonuria, Screening (PKU) Ages 2-14 days Two tests during age range Prostate Specific Antigen (PSA) Ages 40 years and over 84030 with V77.3 84030 with Z13.228 G0103 or 84153 with routine G0103 or 84153 with routine HCP did not list as covered we included in HCP so there would be no disruption of Revised 11/10/2016 HDM Page 12
Annually coverage Rh (D) Incompatibility, Screening Two per calendar year Females only 86901 with V22.0- V23.9 86901 with O09.00- O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z34.93 10/1/16 add Z33.3 Prenatal Visits Prenatal conference with Pediatricians only Prevention of Falls Age 65 years and older 99201-99203 or 99211-99213 with V65.11 97110, 97112, 97116, G0151, or G0159 with V15.88, limited to 40 services each calendar year (= 10 hours of physical therapy) CPT codes 99201-99203 or 99211-99213 with Z76.81 97110, 97112, 97116, G0151, or G0159 with Z91.81, limited to 40 services each calendar year (= 10 hours of physical therapy) Effective 6/1/2013 OR OR 97150 with V15.88, limited to 10 services each calendar year 97150 with Z91.81, limited to 10 services each calendar year OR OR S9131 with V15.88, limited to 10 services each calendar year S9131 with Z91.81, limited to 10 services each calendar year Preventive History and Physical Examinations 9 visits the first 2 years of life Age 2 two per birth year Ages 3-6 - one each year ( based on birth year) Ages 7-99 Male one each calendar year Ages 7-9 Females one each calendar year Ages 10-99 Females one each calendar year (excludes the Well Women s Preventive Examinations procedure/ code combinations) HCP indicates to cover an additional visit at age 30 months for well child Revised 11/10/2016 HDM Page 13
Psychosocial/Behavioral Assessment Effective 1/1/2015 Newborn 21 years 31 services during age range Sensory Screening Hearing Ages 2 months - 10 years---no more than eight tests, Ages 11-21 years ----no more than two tests 96127 with 96127 with 92551, 92552, 92567, 92586, 92587, or V5008 with V20.2 or V72.19 1/1/12 add 92558 92551, 92552, 92567, 92586, 92587, or V5008 with Z00.121, Z00.129, Z01.10, or Z01.118 1/1/12 add 92558 Audiologists are not eligible providers 12/31/11 cancel 92587 12/31/11 cancel 92587 Screening Hearing Newborn Newborn 31 days One in a lifetime 92586 or 92587 with V20.2, V20.31, V20.32, or V72.19 11/1/15 add Z13.5 92586 or 92587 with Z00.110, Z00.111, Z00.121, Z00.129, Z01.10, or Z01.118 Audiologists are not eligible providers 1/1/12 add 92558 1/1/12 add 92558 12/31/11 cancel 92587 12/31/11 cancel 92587 Sexually Transmitted Infections, Behavioral Counseling Interventions to Prevent Males age 11-99 Males - Three hours in a lifetime 99401-99404 with V65.44, V65.45, or V69.2 1/1/12 add G0445 11/1/15 add Z13.5 99401-99404 with Z71.7, Z71.89 Z72.51, Z72.52, or Z72.53 1/1/12 add G0445 Removed code V65.44 for female age 10-99 due to overlapping with HIV Counseling preventing visit maximums from applying correctly Females age 10-99 Eff. 8/1/2012 Females once each calendar year Not covered under PMD 99401, 99402 with V65.45 or V69.2 OR 99403, 99404 with V65.44, V65.45 or V69.2 99401, 99402 with Z71.89, Z72.51, Z72.52 or Z72.53 OR 99403, 99404 with Z71.7, Z71.89 Z72.51, Z72.52, or Z72.53. 1/1/12 add G0445 1/1/12 add G0445 Revised 11/10/2016 HDM Page 14
Sexually Transmitted Infections (STI), Screening Ages 11-21 years No frequency Sickle Cell Disease, Screening Age 0-31 days No frequency 86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, or 87850 with V74.5 83020 or 83021 with V78.2 86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, or 87850 with Z11.3 83020 or 83021 with Z13.0 Syphilis Infection, Screening No frequency Tobacco Use and Tobacco-Caused Disease, Counseling Effective 10/1/2010 5/15/14 One of each CPT code each calendar year Ages 19-99 years Effective 5/16/14 8/31/14 8 total per calendar year Ages 19-99 years 8 total per calendar year Ages 10-99 years Effective 9/1/14 8 total per calendar year Ages 6-99 years 8 total per calendar year 86592 or 86780 with V74.5 Males and Females 99406, 99407, G0436 or G0437 305.1, Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-9 code of 649.03 or 649.00 Males and Females 99406, 99407, G0436 or G0437 305.1, Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-9 code of 649.03 or 649.00 Males and Females 99406, 99407, G0436 or G0437 305.1, 86592 or 86780 with Z11.3 Males and Females 99406, 99407, G0436 or G0437 F17.200-F17.299, or Z72.0, Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-10 codes of O99.330-O99.333 Males and Females 99406, 99407, G0436 or G0437 F17.200-F17.299, or Z72.0, Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-10 codes of O99.330-O99.333 Males and Females 99406, 99407, G0436 or G0437 F17.200-F17.299, or Z72.0, 10/1/16 Cancel G0436, G0437 Revised 11/10/2016 HDM Page 15
Ages 10-99 years Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-9 code of 649.03 or 649.00 Pregnant Females Ages 10-99 for CPT codes 99406 or 99407 with ICD-10 codes of O99.330-O99.333 Tobacco Use and Tobacco-Caused Disease, Medication Effective 10/1/2014 Two 90 day supplies To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. All Food and Drug Administration (FDA)- approved tobacco cessation medications (including both prescription and over-thecounter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. Type 2 Diabetes Mellitus in Adults, Screening Ages 19 years and older Once every 3 calendar years Tuberculin Test Ages 1 month - 21 years 6 tests during age range 82947 or 83036 with V77.1 82947 or 83036 with Z13.1 86580 with V74.1 86580 with Z11.1 O99.330-O99.333 Visual Acuity Screening in Children Newborn age 10 limited to 8 tests in age range Ages 11-21 years limited to 4 tests during age range 99173 or 99174 with V72.0 11/1/14 add V20.2, V20.31 or V20.32 99173 or 99174 with Z01.00 or Z01.01 11/1/14 add Z00.129, Z00.121, Z00.110 or Z00.111 11/1/15 add Z13.5 1/1/16 add 99177 *Women s Preventive Screenings Effective August 1, 2012 Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes Well Woman Preventative Females only beginning at age 10 Effective 8/1/12 CPT codes 99393-99397, G0439, S0612, or S0613 with V70.0 or V72.31 limited to 2 per calendar year Effective 8/1/12 CPT codes 99393-99397, G0439, S0612, or S0613 with Z00.00, Z00.01, Z01.411, or Z01.419 limited to Revised 11/10/2016 HDM Page 16
Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes 2 per calendar year Effective 8/1/12 7/31/13 CPT codes 99383-99387, G0438, or S0610 with V70.0 or V72.31 limited to 1 per calendar year Effective 8/1/12 7/31/13 CPT codes 99383-99387, G0438, or S0610 with V70.0 or V72.31 limited to 1 per calendar year Effective 8/1/13 CPT codes 99383-99387, G0438, or S0610 with V70.0 limited to 1 per calendar year Effective 8/1/13 CPT codes 99383-99387, G0438, or S0610 with Z00.00 or Z00.01 limited to 1 per calendar year CPT codes 99383-99387, G0438, or S0610 with V72.31 limited to 1 per calendar year CPT codes 99383-99387, G0438, or S0610 with Z01.411 or Z01.419 limited to 1 per calendar year Preconception Females only beginning at age 10 One visit per calendar year same procedure codes as above with code V26.49 same procedure codes as above with code Z31.69 10/1/16 add Z31.7 Prenatal Care Females only beginning at age 10 99201-99215 with routine prenatal (see HCP ROUTINE PRENATAL DX), limited to 3 visits each calendar year 99201-99215 with routine prenatal (see HCP ROUTINE PRENATAL DX), limited to 3 visits each calendar year Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost share See end of document for a list of dx codes. 99201-99215 with high risk prenatal (see HCP HIGH RISK PRENATAL DX) 99201-99215 with high risk prenatal (see HCP HIGH RISK PRENATAL DX) 59425 regardless of, limited to 2 visits each calendar year 59426 regardless of, limited to 1 visit each calendar year 59425 regardless of, limited to 2 visits each calendar year 59426 regardless of, limited to 1 visit each calendar year Screening for Gestational Diabetes Females only beginning at age 10 Limit two per calendar year 82947 or 83036 with codes V22.0-V23.9 or 640.00-647.94,648.10-648.74,648.90-82947 or 83036 with codes O09.00-O15.03, O15.2- O23.93, O25.10-O26.43, Revised 11/10/2016 HDM Page 17
Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes 659.93, V91.00-V91.03, V91.09- V91.12 or V91.19-V91.22, V91.29, V91.90-V91.92, V91.99, 671.00, 671.03, 671.10, 671.13, 671.20, 671.23, 671.30, 671.33, 671.50, 671.53, 671.80, 671.83, 671.90, 671.93, 673.00, 673.03, 673.10, 673.13, 673.20, 673.23, 673.30, 673.33, 673.80, 673.83, 674.00, 674.03, 674.50, 674.53675.00, 675.03, 675.10, 675.13, 675.20, 675.23, 675.80, 675.83, 675.90, 675.93, 676.00, 676.03, 676.10, 676.13, 676.20, 676.23, 676.30, 676.33, 676.40, 676.43, 676.60, 676.63, 676.80, 676.83, 676.90, or 676.93 O26.611-O26.93, O29.011- O30.019, O30.031-O30.93, O31.00X-O32.9XX (7 th character 0,1,2,3,4,5, or 9), O33.0-O33.2, O33.3XX-O33.6XX (7 th character 0,1,2,3,4,5, or 9), O33.7-O34.93, O35.0XX-O35.6XX (7 th character 0,1,2,3,4,5,or 9), O35.8XX0- O36.8199, O36.891-O41.93X (7 th character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.10- O42.119, O42.90-O42.919, O43.011-O43.119,O43.191- O43.199, O43.811-O60.03, O60.10X (7 th character 0,1,2,3,4,5, or 9), O60.20X0- O60.20X9, O61.0-O61.1, O6.70- O68, O75.2-O75.3, O75.5, O75.82-O77.0, O80, O86.11, O86.13-O86.29, O88.011- O88.019, O88.111-O88.119, O88.211-O88.219, O88.311- O88.319, O88.811-O88.819, O90.3, O90.5-O90.89, O91.011- O90.019, O91.111-O91.119, O91.211-O91.219, O91.23- O92.019, O92.111-O92.119, O92.20-O92.3, O92.6-O92.79, O98.011-O99.73, O99.820- O9A.53, Z33.1, or Z34.00- Z34.93 12/1/15 add 82951, 82952 10/1/16 delete O33.7 10/1/16 add O33.7XX0-O34.93 and Z33.3 HIV Counseling Females only beginning at age 10 Annually Contraceptive Methods and Counseling Female only beginning at age 10 Annually 99401 or 99402 with V65.44 99401 with codes V25.01-V25.09, V25.40-V25.49, or V25.9 99401 or 99402 with Z71.7 99401 with codes Z30.011-Z30.09, Z30.40-Z30.42, Z30.431, Z30.49 or Z30.9 Revised 11/10/2016 HDM Page 18
Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes 10/1/16 add codes Z30.44, Z30.45, and Z30.46 Sterilization Female only One procedure per lifetime 58565, 58600, 58605, 58611, 58615, 58670 58671, 00851, A4264 with code V25.2 58565, 58600, 58605, 58611, 58615, 58670 58671, 00851, A4264 with code Z30.2 Note: injection code 96372 if Depo-Provera was given was not added to HCR Women s Preventive Coding since we are unable to tie it back to a matching procedure to provide accurate coverage Confirmatory Test Two in a lifetime 58565 has to have a confirmatory test 74740 and 58340 with code V25.8 58565 has to have a confirmatory test 74740 and 58340 with code Z30.8 Medical Contraceptive Methods A4261, A4266,11981, 11983, 57170, 58300, J1055, J1056, J7307, J7300, J7302, J7303, J7304, J7306, S4981, S4989, with codes V25.02, V25.11, V25.13, V25.42, V25.43, V25.49, or V25.5 A4261, A4266,11981, 11983, 57170, 58300, J1055, J1056, J7307, J7300, J7302, J7303, J7304, J7306, S4981, S4989, with codes Z30.013- Z30.019, Z30.42, Z30.430, Z30.431, Z30.433, or Z30.49 12/31/12 cancel J1055 and J1056 12/31/12 cancel J1055 and J1056 01/01/13 add J1050 and codes V25.09, V25.40 and V25.9 01/01/13 add J1050 and codes Z30.09, Z30.40, or Z30.9 02/20/13 add 11976, 11982 and 58301 and code V25.12 07/01/13 add Q0090 01/01/14 cancel Q0090 01/01/14 add J7301 02/20/13 add 11976, 11982 and 58301 and code Z30.432 07/01/13 add Q0090 01/01/14 cancel Q0090 01/01/14 add J7301 Revised 11/10/2016 HDM Page 19
Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes 1/1/16 delete J7302 1/1/16 add J7297, J7298 9/16/16 add J3490 with NDC 50419-0424-01 (Kyleena levonorgestrel-releasing intrauterine system) 10/1/16 add codes Z30.44, Z30.45, and Z30.46 Pharmacy Contraceptive Methods Generic only Brand coverage may be available, contact Customer Service for additional information To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy Breast Feeding Counseling and Support Three per year in conjunction with birth 99402-99404 with modifier TH and code V24.1 99402-99404 with modifier TH and code Z39.1 E0604 is only available for high risk Supplies Pumps and Accessories Pumps - E0602, E0603 with type service H for rental or G for purchase, E0604 rental only E0604 TS H with codes V61.5, 745-745.9, 746-746.9, 747-747.9, 748-748.9, 749-749.25, 750.0-750.16, 758-758.39, 764-764.99, 765-765.19, 765.20-765.29, 770.7, 779.31, 779.34, 783.3. Pumps - E0602, E0603 with type service H for rental or G for purchase, E0604 rental only E0604 TS H with codes P05.00- P07.39, P27.0-P27.9, P29.3, P92.1-P92.9, Q20.0-Q37.9, Q38.1-Q38.3, Q90.0-Q91.7, Q93.3-Q93.9, R63.3, Z64.1 The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage Accessories - A4281, A4282, A4283, A4285, A4286 Accessories - A4281, A4282, A4283, A4285, A4286 Screening and Counseling for Interpersonal and Domestic Violence Females only beginning at age 10 Annually 99401-99404 with codes V61.11, V61.12, V61.21, V61.22, V62.83 99401-99404 with codes Z69.010-Z69.12, Z69.82 Revised 11/10/2016 HDM Page 20
Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/15 Notes Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults Females only beginning at age 10 Annually Effective 2/1/14 99401-99404 with codes V61.10, V61.11, V61.12, V61.20, V61.21, V61.22, V62.83 Effective 2/1/14 99401-99404 with codes Z65.9, Z69.010-Z69.12, Z69.82, Z71.89 HCP ROUTINE PRENATAL DX (ICD9) V22,V220,V221,V222, V28,V280,V281,V282,V283,V284,V285,V286,V2881,V2882,V2889,V289, V616, V617, V7242, V89, V890, V8901, V8902, V8903, V8904, V8905,V8909,64300,64303,64410,64413,64510,64513,65820,65823,67100,67103,6711,67110,67111,67113,67180,67183,67600,67603,67610,67613,67620, 67623,67630,67633,67640,67643,67650,67653,67660,67663,67680,67683,67690,67693 HCP ROUTINE PRENATAL DX (ICD10 Conversion Effective 10/1/2015) O21.0, O22.00-O22.13, O22.40-O22.43, O22.8X1-O22.8X9, O42.10-O42.119, O47.00-O48.0, O92.011-O92.019, O92.111-O92.119, O92.20-O92.3, O92.5-O92.79, Z03.71-Z03.79, Z32.01, Z33.1, Z33.3, Z34.00-Z36, Z64.0 HCP HIGH RISK PRENATAL DX (ICD9) V23,V230,V231,V232,V233, V234,V2341,V2342,V2349,V235,V237,V238,V2381,V2382,V2383,V2384,V2385,V2386,V2387,V2389,V239,V91,V910,V9100,V9101 V9102,V9103,V9109,V911,V9110,V9111,V9112,V9119,V912,V9120,V9121,V9122,V9129,V919,V9190,V9191,V9192,V9199,630, 631,6310,6318,632,633,6330, 63300,63301,6331,63310,63311,6332,63320,63321,6338,63380,63381,6339,63390,63391,634,6340,63400,63401,63402,6341,63410,63411,63412,6342, 63420,63421,63422,6343,63430,63431,63432,6344,63440,63441,63442,6345,63450,63451,63452,6346,63460,63461,63462,6347,63470,63471,63472, 6348,63480,63481,63482,6349,63490,63491,63492,635,6350,63500,63501,63502,6351,63510,63511,63512,6352,63520,63521,63522,6353,63530,63531, 63532,6354,63540,63541,63542,6355,63550,63551,63552,6356,63560,63561,63562,6357,63570,63571,63572,6358,63580,63581,63582,6359,63590,63591, 63592,637,6370,63700,63701,63702,6371,63710,63711,63712,6372,63720,63721,63722,6373,63730,63731,63732,6374,63740,63741,63742,6375,63750, 63751,63752,6376,63760,63761,63762,6377,63770,63771,63772,6378,63780,63781,63782,6379,63790,63791,63792,638,6380,6381,6382,6383,6384,6385, 6386,6387,6388,6389,64000,64003,6408,64080,64083,64090,64093,64100,64103,64110,64113,64120,64123,64130,64133,64180,64183,64190,64193,64200, 64203,64210,64213,64220,64223,64230,64233,64240,64243,64250,64253,64260,64263,64270,64273,64290,64293,64310,64313,64320,64323,64380, 64383,64390,64393,64400,64403,64420,64520,64523,64600,64603,64610,64613,64620,64623,64630,64633,64640,64643,64650,64653,64660, 64663,64670,64673,64680,64683,64690,64693,64700,64703,64710,64713,64720,64723,64730,64733,64740,64743,64750,64753,64760,64763,64780,64783, 64790,64793,64800,64803,64810,64813,64820,64823,64830,64833,64840,64843,64850,64853,64860,64863,64870,64873,64880,64883,64890,64893,64900, 64903,64910,64913,64920,64923,64930,64933,64940,64943,64950,64953,64960,64963,64970,64973,65100,65103,65110,65113,65120,65123,65130,65133, 65140,65143,65150,65153,65160,65163,65170,65173,65180,65183,65190,65193,65200,65203,65210,65213,65220,65223,65230,65233,65240,65243,65250, 65253,65260,65263,65270,65273,65280,65283,65290,65293,65300,65303,65310,65313,65320,65323,65330,65333,65340,65343,65350,65353,65360,65363, 65370,65373,65380,65383,65390,65393,65400,65403,65410,65413,65420,65423,65430,65433,65440,65443,65450,65453,65460,65463,65470,65473,65480, 65483,65490,65493,65500,65503,65510,65513,65520,65523,65530,65533,65540,65543,65550,65553,65560,65563,65570,65573,65580,65583,65590,65593, 65600,65603,65610,65613,65620,65623,65630,65633,65640,65643,65650,65653,65660,65663,65670,65673,65680,65683,65690,65693,65700,65703,65800, 65803,65810,65813,65840,65843,65880,65883,65890,65893,65940,65943,65950,65953,65960,65963, 67120,67123,67130,67133,67150,67153, 67190,67193, 67500,67503,67510,67513,67520,67523,67580,67583,67590,67593,67800,67803,67810,67813,67900,67903,67910,67913 HCP HIGH RISK PRENATAL DX (ICD10 Conversion Effective 10/1/2015) O00-O07.4, O09.00-O10.019, O10.111-O10.119, O10.211-O10.219, O10.311-O10.319, O10.411-O10.419, O10.911-O10.919, O11.1-O15.03, O15.9-O20.9, O21.1-O21.9, O22.20- O22.33, O22.50-O22.53, O22.90-O24.019, O24.111-O24.119, O24.311-O24.319, O24.410-O24.419, O24.811-O24.819, O24.911-O24.919, O25.10-O25.13, O26.00-O26.43, O26.611-O26.619, O26.711-O26.719, O26.811-O26.93, O29.011-O30.93, O31.00X-O32.9XX (7 th character 0,1,2,3,4,5, or 9), O33.0-O33.2, O33.3XX-O33.6XX (7 th character 0,1,2,3,4,5, or 9), O33.7XX0-O34.93, O35.0XX-O41.93X (7 th Character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.90-O42.919, O43.011-O46.93, O48.1-O60.03, O60.10X (7 th character 0,1,2,3,4,5, or 9), O60.20X (7 th character 0,1,2,3,4,5,or 9), O91.011-O91.019, O91.111-O91.119, O91.211-O91.219, O91.23, O98.011-O98.019, O98.111-O98.119, O98.211-O98.219, O98.311-O98.319, O98.411-O98.419, O98.511-O98.519, O98.611-O98.619, O98.711-O98.719, O98.811-O98.819, O98.911-O98.919, O99.011-O99.019, O99.111-O99.119, O99.210-O99.213, O99.280-O99.283, O99.310-O99.313, O99.320 O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.411-O99.419, O99.511-O99.519, Revised 11/10/2016 HDM Page 21
O99.611-O99.619, O99.711-O99.719, O99.810, O99.820, O99.830, O99.840-O99.843, O99.89, O9A.111-O9A.119, O9A.211-O9A.219, O9A.311-O9A.319, O9A.411-O9A.419, O9A.511-O9A.519, Z33.2 10/1/16 delete O33.7 The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows: Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force. Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children, adolescent, and adult) Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures). Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.) All providers (including those outside the state of Alabama) must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Cross and Blue Shield of Alabama member. If the preventive services section of a plan's benefit booklet refers to AlabamaBlue.com, the preventive services and immunizations in this document will be covered by the health plan. However, a group may decide to delay the effective date for coverage until the group's plan year for any new preventive services and immunizations recently added to this list. If a plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from an office or other facility visit. In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of the benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for a visit is not routine preventive services and/or routine immunizations. If you have any questions about a plan s benefits, you may call our Customer Service Department at the number on the back of the ID card. Revised 11/10/2016 HDM Page 22