Important Notes: Patient Protection and Affordable Care Act (PPACA) requires the to provide coverage for the following services at 100 percent only when provided by a Legacy + Network provider. This is only a general summary of the no cost preventive services specific to the Legacy Employee Health Plan. o Contact PacificSource at 844 520 5347 to verify whether a specific service is an eligible no cost preventive service. Eligible services qualifying for no cost status must: o Meet all applicable age, medical history, frequency or other requirements, AND o Be billed separately or be the primary purpose of the office visit, AND o Be properly coded (CPT and ICD 10 codes, as appropriate) by the provider. Immunization doses, recommended ages, and recommended populations vary by immunization. Screening services performed to monitor an existing illness, such as glucose testing for a person diagnosed as diabetic, are not considered preventive and will not be paid under this preventive benefit. Services to treat or assess a medical condition already diagnosed (such as diabetes or hypertension) are not considered preventive and will not be paid under this preventive services benefit. Services qualifying for no cost status are updated as required and are subject to change. Abdominal aortic aneurysm (AAA) Service Who Details Alcohol misuse reduction and Autism/developmental Bacteriuria Blood pressure BRCA One time for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. Screening and interventions to reduce alcohol misuse by adolescents, including pregnant, in primary care settings. Screening for ages birth to 21 years Screening for asymptomatic bacteriuria with urine culture for pregnant at 12 to 16 weeks' gestation or at the first prenatal visit, if later. Screening for high blood pressure in adults 18 and older when part of a well adult visit. whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic and evaluation for BRCA testing. Page 1 of 5 Updated 08/2017
Service Who Details Breast cancer drug treatment discussion Breast cancer mammography Breastfeeding and support Cardiovascular disease aspirin use Cervical cancer /pap smear Chemoprevention of dental caries discussion Chlamydial infection Cholesterol Cholesterol abnormality Colorectal cancer Congenital hypothyrodism Contraceptive methods (FDA approved) and Clinicians discuss chemoprevention with at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention. Does not include prescription drug costs. Screening mammography for with or without clinical breast examination (CBE), every 1 2 years for aged 40 and older. Counseling and support during pregnancy and after birth to promote and support breastfeeding. Includes coverage for one breast pump per delivery. Counseling on the use of aspirin for men age 45 to 79 years and age 55 to 79 years when the potential benefit due to a reduction in heart attack outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Does not include medication cost. Screening for cervical cancer in sexually active adolescents and. Primary care clinician s discussion during wellness visit about prescribing oral fluoride supplementation at recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. Does not include the prescription cost. Screening for all pregnant, sexually active Lipid disorders for adolescents. Dyslipidemia for ages 24 months to 21 years Screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy. The risks and benefits of these methods vary. Screening for congenital hypothyroidism (CH) in newborns. Coverage for sterilization procedures, contraceptive medications, diaphragms and cervical caps, hormonal methods and emergency contraception. Includes cost of insertion and removal of devices. Page 2 of 5 Updated 08/2017
Depression All Screening for depression in adults and major depressive disorder (MDD) in children and adolescents. Diabetes Domestic and interpersonal violence and Folic acid supplementation Gestational diabetes Gonorrhea Screening for type 2 diabetes in pregnant and asymptomatic individuals. All adults. Counseling for all planning or capable of pregnancy to take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Does not include the supplement cost. All pregnant 24 28 weeks; high risk can be screened twice. Screening for all pregnant, sexually active Healthy diet Behavioral dietary for adult patients with heart disease, hypertension, obesity, diabetes, tobacco use or lipiod disorders. Counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Healthy diet, intensive Intensive behavioral dietary for adult patients with heart disease, hypertension, obesity, diabetes, tobacco use or lipiod disorders. Intensive can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Limited to 2 visits per calendar year. Hearing tests Screening for hearing loss in individuals ages birth through 21 once per calendar year. Hemoglobinopathies (sickle cell) Hepatitis B HIV Human papillomavirus (HPV) DNA testing Screening for sickle cell disease in newborns. Screening for all pregnant, sexually active Screening for all adolescents. Screening for adults age 30 and older. Page 3 of 5 Updated 08/2017
Immunizations: infant, child and adolescent o Diphtheria, Tetanus, Pertussis o Haemophilus influenzae type b o Hepatitis A o Hepatitis B o Human Papillomavirus o Inactivated Poliovirus o Influenza o Measles, Mumps, Rubella o Meningococcal o Pneumococcal o Rotavirus o Varicella Immunizations: adult o Diphtheria, Tetanus, Pertussis o Hepatitis A o Hepatitis B o Herpes Zoster (ages 60 and older) o Human Papillomavirus (catch up through age 26) o Influenza o Measles, Mumps, Rubella o Meningococcal o Pneumococcal o Varicella Iron deficiency (anemia) Iron supplementation in children and pregnant Routine for iron deficiency anemia in asymptomatic pregnant and individuals ages birth to 21. Counseling on routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia. Does not include the supplement cost. Lead Screening for ages birth to 21. Metabolic panel Obesity and : Obesity and : Obesity, intensive and adolescents and adults Screenings including galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17 d; phenylanine (PKU); and thyroxinephenylketonuria (PKU) in newborns. Screening and of adult patients for obesity and offer intensive and behavioral interventions to promote sustained weight loss for obese adults. Screening and of children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Intensive behavioral for individuals age 6 and older. Limited to two visits per calendar year. Page 4 of 5 Updated 08/2017
Osteoporosis aged 60 and older be screened routinely for osteoporosis that routine begin at age 60 for at increased risk for osteoporotic fractures. Prenatal well woman examination Prophylactic medication for gonorrhea Prostate cancer Rh incompatibility Sexually transmitted infections (STI) Men Rubella Screening for Rubella. Syphilis Tobacco use and pregnant Routine prenatal obstetrical office visits/low risk, uncomplicated pregnancies; all eligible no cost preventive lab services; tobacco cessation specific to pregnant ; and immunizations directed to pregnant. Prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. Prostate Specific Antigen (PSA) for prostate cancer for men ages 40 and older. Rh (D) blood typing and antibody testing for all pregnant during their first visit for pregnancy related care; repeated Rh (D) antibody testing for all unsensitized Rh (D) negative at 24 28 weeks' gestation, unless the biological father is known to be Rh (D) negative. High intensity behavioral to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. Limited to two visits per calendar year. Screening for all pregnant, sexually active Clinicians ask all adults and pregnant about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Tuberculosis Screening for ages birth to 21 years Visual acuity in children Screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. Wellness examinations All Includes well baby, well child and well adult examinations. Page 5 of 5 Updated 08/2017