Child and Adult Preventive Care Services Adult and Child Preventive Care Services will meet the requirements as determined by federal and state law. Cvered preventive care services prvided by a Participating Prvider are payable at 100% with n Deductible, Cpayment r Cinsurance. These services fall under fur brad categries as shwn belw. These listings will be updated as required by federal r state law. 1. Services with an A r B rating frm the United States Preventive Services Task Frce. Screening fr abdminal artic aneurysm - a ne-time screening fr abdminal artic aneurysm (AAA) by ultrasngraphy in men age 65 t 75, wh have smked. Screening and cunseling t reduce alchl misuse - screening and behaviral cunseling interventins t reduce alchl misuse by adults, including pregnant wmen, in primary care settings. Aspirin t prevent CVD: men - the use f aspirin fr men age 45 t 79 years, when the ptential benefit due t a reductin in mycardial infarctins utweighs the ptential harm due t an increase in gastrintestinal hemrrhage. Aspirin t prevent CVD: wmen - the use f aspirin fr wmen age 55 t 79 years, when the ptential benefit f a reductin in ischemic strkes utweighs the ptential harm f an increase in gastrintestinal hemrrhage. Screening fr bacteriuria - screening fr asymptmatic bacteriuria with urine culture fr pregnant wmen at the later f 12 t 16 weeks' gestatin r at the first prenatal visit. Screening fr high bld pressure - screening fr high bld pressure in adults age 18 and lder. Cunseling related t BRCA screening - wmen whse family histry is assciated with an increased risk fr deleterius mutatins in BRCA1 r BRCA2 genes, wh are referred fr genetic cunseling and evaluatin fr BRCA testing. Screening fr breast cancer (mammgraphy) - annual lw-dse mammgraphy fr wmen, with r withut clinical breast examinatin (CBE), fr wmen age 35 and lder. Lw-dse mammgraphy means the X-ray examinatin f the breast using equipment dedicated specifically fr mammgraphy, including an X-ray tube, filter, cmpressin devise, screens, films and cassettes, with an average radiatin expsure delivery f less than ne rad mid-breast, with tw views fr each breast. Chempreventin f breast cancer - clinicians discussin f chempreventin with wmen at high risk fr breast cancer and at lw risk fr adverse effects f chempreventin. Interventins t supprt breast feeding - interventins during pregnancy and after birth t prmte and supprt breastfeeding. Screening fr Human Papillmavirus and cervical cancer (Pap Smear) - diagnstic examinatin fr early detectin f cervical cancer, including the prvider s charge fr administratin f the test, fr any cvered female age 18 r lder, nt t exceed ne per calendar year fr: a cnventinal Pap smear screening r a screening using liquid-based cytlgy methds, as apprved by the United States Fd and Drug Administratin (FDA), alne r in cmbinatin with a test apprved by the FDA fr the detectin f the human Page 1 f 6
papillmavirus. A screening test must be perfrmed in accrdance with the guidelines adpted by the American Cllege f Obstetricians and Gyneclgists r anther similar natinal rganizatin f medical prfessinals recgnized by the Insurance Cmmissiner. Screening fr chlamydial infectin: nn-pregnant wmen - screening fr chlamydial infectin fr all sexually active nn-pregnant wmen age 24 and yunger and fr lder nnpregnant wmen wh are at increased risk. Screening fr chlamydial infectin: pregnant wmen - screening fr chlamydial infectin fr all pregnant wmen age 24 and yunger and fr lder pregnant wmen wh are at increased risk. Screening fr chlesterl abnrmalities: men 35 and lder - screening fr men age 35 and lder fr lipid disrders. Screening fr chlesterl abnrmalities: men yunger 35 - screening fr men age 20 t 35 fr lipid disrders if they are at increased risk fr crnary heart disease. Screening fr chlesterl abnrmalities: wmen 45 and lder - screening fr wmen age 45 and lder fr lipid disrders if they are at increased risk fr crnary heart disease. Screening fr chlesterl abnrmalities: wmen yunger than 45 - screening fr wmen age 20 t 45 fr lipid disrders if they are at increased risk fr crnary heart disease. Screening fr clrectal cancer - screening fr detectin f clrectal cancer fr an Insured Persn at least 50 years f age and at nrmal risk fr develping cancer, limited t: an annual fecal ccult bld test and a flexible sigmidscpy nce every five years; r a clnscpy nce every ten years. Chempreventin f dental caries - primary care clinicians prescriptin fr ral fluride supplementatin at currently recmmended dses t preschl children lder than 6 mnths f age whse primary water surce is deficient in fluride. Screening fr depressin: adults - screening f adults fr depressin when staff-assisted depressin care supprts are in place t assure accurate diagnsis, effective treatment, and fllw-up. Screening fr depressin: adlescents - screening f adlescents (12 t 18 years f age) fr majr depressive disrder (MDD) when systems are in place t ensure accurate diagnsis, psychtherapy (cgnitive-behaviral r interpersnal), and fllw-up. Screening fr diabetes - screening fr type 2 diabetes in asymptmatic adults with sustained bld pressure (either treated r untreated) greater than 135/80 mm Hg. Cunseling fr a healthy diet - intensive behaviral dietary cunseling fr adult patients with hyperlipidemia and ther knwn risk factrs fr cardivascular and diet-related chrnic disease. Intensive cunseling can be delivered by primary care clinicians r by referral t ther specialists, such as nutritinists r dietitians. Supplementatin with flic acid - a daily supplement cntaining 0.4 t 0.8 mg (400 t 800 µg) f flic acid fr all wmen planning n r capable f pregnancy. Screening fr gnrrhea: wmen screening fr all sexually active wmen, including thse wh are pregnant, fr gnrrhea infectin if they are at increased risk fr infectin (that is, if they are yung r have ther individual r ppulatin risk factrs). Prphylactic medicatin fr gnrrhea: newbrns - prphylactic cular tpical medicatin fr all newbrns against gncccal phthalmia nenatrum. Page 2 f 6
Screening fr hearing lss - screening test fr hearing lss fr a child frm birth thrugh the date the child is 30 days ld; and Medically Necessary diagnstic fllw-up care t the screening test fr a child frm birth thrugh the date the child is 24 mnths ld. Screening fr hemglbinpathies - screening fr sickle cell disease in newbrns. Screening fr hepatitis B - screening fr hepatitis B virus (HBV) infectin in pregnant wmen at their first prenatal visit. Screening fr hepatitis C - screening fr hepatitis C virus (HCV) infectin in persns at high risk fr infectin and a ne-time screening fr HCV infectin t adults brn between 1945 and 1965. Screening fr HIV - screening fr human immundeficiency virus (HIV) in all adlescents and adults at increased risk fr HIV infectin. Screening fr cngenital hypthyrdism - screening fr cngenital hypthyridism (CH) in newbrns. Screening fr irn deficiency anemia - screening fr irn deficiency anemia in asymptmatic pregnant wmen. Irn supplementatin in children - rutine irn supplementatin fr asymptmatic children age 6 t 12 mnths wh are at increased risk fr irn deficiency anemia. Screening and cunseling fr besity: adults screening fr all adult patients fr besity and intensive cunseling and behaviral interventins t prmte sustained weight lss fr bese adults. Screening and cunseling fr besity: children screening fr children age 6 years and lder fr besity and referral t cmprehensive, intensive behaviral interventins t prmte imprvement in weight status. Screening fr steprsis screening fr wmen age 65 and lder fr a qualified individual fr medically accepted bne mass measurement t detect lw bne mass and t determine the Insured Persn s risk f steprsis and fractures assciated with steprsis. A qualified individual is: a pstmenpausal wman wh is nt receiving estrgen replacement therapy; an individual with vertebral abnrmalities, primary hyperparathyridisn, r a histry f bne fractures; r an individual wh is receiving lngterm gluccrticid therapy r being mnitred t assess the respnse t r efficacy f an apprved steprsis drug therapy. Screening fr PKU - screening fr phenylketnuria (PKU) in newbrns. Screening fr Rh incmpatibility: first pregnancy visit - Rh (D) bld typing and antibdy testing fr all pregnant wmen during their first visit fr pregnancy-related care. Screening fr Rh incmpatibility: 24 t 28 weeks gestatin - repeated Rh (D) antibdy testing fr all unsensitized Rh (D)-negative wmen at 24 t 28 weeks' gestatin, unless the bilgical father is knwn t be Rh (D)-negative. Cunseling fr STIs - high-intensity behaviral cunseling t prevent sexually transmitted infectins (STIs) fr all sexually active adlescents and fr adults at increased risk fr STIs. Screening fr syphilis: nn-pregnant persns screening fr persns at increased risk fr syphilis infectin. Page 3 f 6
Screening fr syphilis: pregnant wmen - screening fr all pregnant wmen fr syphilis infectin. Cunseling fr tbacc use - clinicians ask all adults abut tbacc use and prvide tbacc cessatin interventins fr thse wh use tbacc prducts. Cunseling fr tbacc use - clinicians ask all pregnant wmen abut tbacc use and prvide augmented, pregnancy-tailred cunseling fr thse wh smke. Screening fr visual acuity in children - screening t detect amblypia, strabismus, and defects in visual acuity in children yunger than 5 years ld. 2. Immunizatins fr children, adlescents, and adults recmmended by the Advisry Cmmittee n Immunizatin Practices f the Centers fr Disease Cntrl and Preventin. Immunizatins fr Children ages 0 thrugh 6 years: Hepatitis B Rtavirus Diptheria, Tetanus, Pertussis Haemphilus influenzae type b cnjugate (Hib) Pneumcccal Inactivated plivirus (IPV) Influenza (seasnal), including H1N1 influenza Measles, mumps, and rubella (MMR) Varicella Hepatitis A (HepA) Meningcccal Pli Any ther immunizatin required by law fr the child Immunizatins fr Children ages 7 thrugh 18 years: Tetanus, Diptheria, Pertusis (Td/Tdap) Human papillmavirus (HPV) Meningcccal Influenza (seasnal) Pneumcccal plysaccharide (PPSV) Hepatitis A (HepA) Hepatitis B Inactivated plivirus (IPV) Measles, mumps, and rubella (MMR Varicella Varicella Page 4 f 6
Immunizatins fr adults ver age 18: Tetanus, Diptheria, Pertusis (Td/Tdap) Human papillmavirus (HPV) Varicella Herpes zster Measles, mumps, and rubella (MMR) Influenza (seasnal) Pneumcccal plysaccharide (PPSV) Hepatitis A (HepA) Hepatitis B Meningcccal 3. Preventive care and screenings fr infants, children and adlescents as prvided fr in the cmprehensive guidelines supprted by the Health Resurces and Services Administratin. Cvered Services are listed in the Peridicity Schedule f the Bright Futures Recmmendatins fr Pediatric Preventive Health Care and the Unifrm Panel f the Secretary s Advisry Cmmittee n Heritable Disrders in Newbrns and Children. Preventive Physical Exams at Recmmended Intervals Measurements length, height, weight, head circumference, weight fr length, bdy mass index, bld pressure Sensry Screening Visin Hearing Develpmental/Behaviral Assessment Develpmental Screening Autism Screening at the ages f 18 and 24 mnths, and as therwise required by federal law Develpmental Surveillance Psychscial/Behaviral Assessment Alchl and Drug Use Assessment Prcedures Newbrn Metablic/Hemglbin Screening Immunizatin Hematcrit r Hemglbin Lead Screening Tuberculin Test Page 5 f 6
Dyslipidemia Screening Sexually Transmitted Infectin (STI) Screening Cervical Dysplasia Screening Oral Health Risk Assessment and pssible ral fluride supplementatin 4. Preventive care and screening fr wmen prvided fr in the guidelines supprted by the Health Resurces and Services Administratin. Annual well-wman preventive care visit fr adult wmen t btain the recmmended preventive services that are age and develpmentally apprpriate, including precnceptin and prenatal care. When apprpriate, this visit can include ther cvered Adult Preventive Care Services. Screening fr gestatinal diabetes fr pregnant wmen between 24 and 28 weeks f gestatin and at the first prenatal visit fr pregnant wmen identified t be at high risk fr diabetes. High-risk human papillmavirus DNA testing in wmen with nrmal cytlgy results, beginning at 30 years f age and ccurring n mre frequently than nce every three years. Annual cunseling n sexually transmitted infectins fr all sexually active wmen. Annual screening and cunseling fr human immune-deficiency virus infectin fr all sexually active wmen. Prescripted FDA-apprved cntraceptive methds, sterilizatin prcedures and patient educatin and cunseling fr all wmen with reprductive capacity, including Injectable Drugs and implants, intra-uterine devices, diaphragms, and the prfessinal services assciated with them. Cmprehensive lactatin supprt and cunseling by a trained prvider during pregnancy and/r in the pstpartum perid and rental f breastfeeding equipment. Annual screening and cunseling fr wmen fr interpersnal and dmestic vilence. Page 6 f 6