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Summary Information for Preventive Care Services without Cost Sharing Important: This summary lists all preventive care services required to be provided by non-grandfathered plans under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with the provisions of this summary, the provisions of this summary will supersede the terms of the Plan. Category Summary Required Preventive Care Services Service Applies only to non-grandfathered plans (Grandfathered status in Plan document) Covered In-Network Preventive Services for Adults Covered In-Network Preventive Services for Women, Including Pregnant Women Revised_071113_Documentation Department Recommendation Abdominal aortic aneurysm One-time screening by ultrasonography in men aged 65 to 75 who have ever smoked Alcohol misuse Screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse by adults Aspirin to prevent CVD Use of aspirin for men aged 45 to 79 when potential benefits of reduction in myocardial infarction outweighs potential harm in increase in GI hemorrhage and for women aged 55 to 79 when potential benefits of reduction in ischemic strokes outweighs potential harm in increase in GI hemorrhage (covered only when prescribed by a health care provider) Blood pressure screening Screening in adults aged 18 and older Cholesterol screening Screening for all men aged 35 and older, and for men aged 20 to 35 at risk for CHD; screening for women aged 45 and older at risk for CHD, and for women aged 20 to 45 at risk for CHD Colorectal cancer screening Screening for adults beginning at age 50 and continuing until age 75 using fecal occult blood testing, sigmoidoscopy and colonoscopy (includes cost of polyp removal) Depression Screening for adults when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow-up Diabetes (type 2) Screening for asymptomatic adults with sustained BP (treated or untreated) greater than 135/80 Diet Intensive behavioral dietary counseling (by primary care clinicians or specialists such as dieticians or nutritionists) for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease HIV Screening for all adults at increased risk (includes HIV test) Immunization vaccines for adults Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza; Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; Varicella (doses, recommended ages and recommended populations vary) Obesity Screening for all adults and offer of intensive counseling and behavioral interventions to promote sustained weight loss for obese adults Sexually transmitted infection (STI) High-intensity behavioral counseling to prevent STIs for adults at increased risk Syphilis Screening for all adults at increased risk Tobacco use Screening for tobacco use for all adults and cessation interventions for tobacco users (includes prescription-drug coverage) Alcohol misuse Screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse by pregnant women Anemia Routine screening for iron-deficiency anemia for asymptomatic pregnant women Bacteriuria Screening for pregnant women at 12-16 weeks’ gestation or at the first prenatal visit, if later, for asymptomatic bacteriuria with urine culture BRCA screening (Breast Cancer Susceptibility Genes 1 and 2) Referrals to genetic counseling and evaluation for BCRA testing for women with family history of increased risk for deleterious mutations in BCRA 1 and BCRA 2 genes (includes genetic counseling and BCRA test) Summary Information for Preventive Care Services without Cost Sharing Important: This summary lists all preventive care services required to be provided by non-grandfathered plans under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with the provisions of this summary, the provisions of this summary will supersede the terms of the Plan. Category Summary Required Preventive Care Services Applies only to non-grandfathered plans (Grandfathered status in Plan document) Service Recommendation Covered In-Network Preventive Services for Women, Including Pregnant Women, continued Breast cancer chemoprevention Counseling for women at high risk for breast cancer and low risk for adverse effects of chemoprevention, including potential benefits and harms of chemoprevention Breast cancer mammography Screening, with or without clinical breast examination, every 1-2 years for women aged 40 and older Breastfeeding* Comprehensive lactation support and counseling by a trained provider during pregnancy or postpartum, and costs for renting breastfeeding equipment, for each birth for the duration of breastfeeding (may include purchase instead of rental) Cervical cancer Screening for sexually active women Chlamydia infection Screening for all sexually active non-pregnant women aged 24 and younger, all pregnant women aged 24 and younger and older pregnant and non-pregnant women at increased risk Contraception*† All FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling, excluding abortifacient agents, for all women with reproductive capacity as prescribed in writing by a Physician, Physician’s Assistant, or Nurse Practitioner within the legally appointed scope of his or her license (These charges shall be paid as Routine preventive care, as described in the Plan’s Schedule of Benefits. Covered services include follow up and management of side effects, counseling for continued adherence, and device removal. All generic contraceptive drugs and all brand contraceptive drugs that do not have a generic equivalent shall be covered at 100% with no co-payment. All brand contraceptive drugs that do have a generic equivalent shall be covered at the co-payments stated in the Plan’s Schedule of Benefits.) Domestic violence screening* Annual screening and counseling for interpersonal and domestic violence (can include brochures or other assessment tools) Folic acid Supplements for women planning or capable of pregnancy containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid (covered only when prescribed by a health care provider) Gestational diabetes* Screening between 24 and 28 weeks’ gestation and at first prenatal visit for women at high risk for diabetes Gonorrhea Screening for all sexually active women, including those who are pregnant if at increased risk Hepatitis B Screening for pregnant women at their first prenatal visit HPV DNA* HPV DNA testing for high-risk women with normal cytology results every 3 years beginning at age 30 Osteoporosis Routine screening for women aged 65 and older, but beginning at age 60 for women at increased risk for osteoporotic fractures Rh incompatibility Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care and repeated Rh (D) antibody testing for un-sensitized Rh (D)-negative women at 24-28 weeks’ gestation, unless biological father is known to be Rh (D) negative STI/HIV* Annual counseling on STI and annual counseling and screening for HIV for all sexually active women (includes HIV test) Syphilis Screening for all pregnant women Tobacco use Screening for tobacco use for all pregnant women and augmented, pregnancy-tailored counseling for those who smoke (includes prescription-drug coverage) Revised_071113_Documentation Department Summary Information for Preventive Care Services without Cost Sharing Important: This summary lists all preventive care services required to be provided by non-grandfathered plans under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with the provisions of this summary, the provisions of this summary will supersede the terms of the Plan. Category Summary Required Preventive Care Services Service Applies only to non-grandfathered plans (Grandfathered status in Plan document) Covered In-Network Preventive Services for Women, Including Pregnant Women, continued Well-woman visits* Recommendation Annual (or more frequent if necessary) visits to obtain recommended age-appropriate and developmentally appropriate preventive services, including preconception and prenatal care *Non-grandfathered plans are required to provide coverage without cost sharing in the first Plan Year that begins on or after August 1, 2012. †Group health plans sponsored by certain religious employers are exempt from the requirement to cover contraceptive services. The definition of religious employer for purposes of the exemption is based solely on Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code, which primarily concerns churches and other houses of worship. A house of worship is not excluded from the exemption because it provides charitable social services to, or employs, persons of different religious faiths. Eligible non-exempt, nonprofit religious employers that object to contraceptive coverage on religious grounds are not required to provide contraceptive coverage under the plan. An eligible organization is one that (1) opposes providing coverage for some or all of any contraceptive services otherwise required to be covered, on account of religious objections; (2) is organized and operates as a nonprofit entity; (3) holds itself out as a religious organization; and (4) self-certifies that it meets these criteria in accordance with the provision of the final regulations. An eligible organization must provide a copy of its self-certification to the plan’s third-party administrator by the first plan year beginning on or after January 1, 2014. The third-party administrator must provide or arrange separate payments for contraceptive services for the women in the health plan of the organization at no cost to the women or to the organization. The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not specify the frequency, method, treatment, or setting for the provision of that service, the Plan can use reasonable medical management techniques (which generally limit or exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any coverage limitations under the Plan. Thus, to the extent not specified in a recommendation or guideline, a plan may rely on the relevant evidence base and these established techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. Plans retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost sharing for branded drugs if a generic version is available and is just as effective and safe. Covered In-Network Preventive Services for Children Revised_071113_Documentation Department Alcohol and drug use Assessments for adolescents Autism Screening for children at 18 and 24 months Behavioral assessments Assessments for children of all ages (0-11 months, 1-4 years, 510 years, 11-14 years, 15-17 years) Blood pressure screening Screening for children of all ages (0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years) Cervical dysplasia Screening for sexually active females Congenital hypothyroidism Screening for newborns Depression Screening of adolescents aged 12-18 years for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy and follow-up Developmental screening Screening for children under age 3 years and surveillance throughout childhood Dyslipidemia Screening for children at higher risk of lipid disorders (1-4 years, 5-10 years, 11-14 years, 15-17 years) Fluoride Chemoprevention of dental caries Supplements for children older than six months of age without fluoride in their water source Gonorrhea ocular prophylaxis Prophylactic ocular topical medication for all newborns Hearing Screening for all newborn Height, weight, body mass index, head circ., and BP Measurements for children (0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years) Hematocrit or Hemoglobin Screening for children Hemoglobinopathies (sickle-cell disease) Screening for newborns Heritable Disorders Screening for newborns HIV Screening for adolescents at increased risk (includes HIV test) Hypothyroidism Screening for congenital hypothyroidism in newborns Summary Information for Preventive Care Services without Cost Sharing Important: This summary lists all preventive care services required to be provided by non-grandfathered plans under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with the provisions of this summary, the provisions of this summary will supersede the terms of the Plan. Category Summary Required Preventive Care Services Service Applies only to non-grandfathered plans (Grandfathered status in Plan document) Covered In-Network Preventive Services for Children, continued Covered In-Network Preventive Drugs Revised_071113_Documentation Department Recommendation Immunization vaccines for children from birth to age 18 Diphtheria, Tetanus, Pertussis ; Haemophilus influenzae type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated Poliovirus; Influenza; Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; Varicela (doses, recommended ages, and recommended populations vary) Iron supplementation Supplements for children aged 6 to 12 months at risk for anemia (covered only when prescribed by a health care provider) Lead Screening for children at risk of exposure Medical History Screening for all children throughout development (0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years) Obesity Screening for children aged 6 years and older and offer of/referral to comprehensive, intensive behavioral interventions to promote improvement in weight status Oral health Risk assessment for young children (0-11 months, 1-4 years, 5-10 years) Phenylketonuria (PKU) Screening for newborns STI High-intensity behavioral counseling to prevent STIs for all sexually active adolescents Tuberculin testing Testing for children at increased risk of tuberculosis (0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years) Vision screening Screening for all children; Screening to detect amblyopia, strabismus and defects in visual acuity for children younger than 5 years Aspirin to prevent CVD Use of aspirin for men aged 45 to 79 when potential benefits of reduction in myocardial infarction outweighs potential harm in increase in GI hemorrhage and for women aged 55 to 79 when potential benefits of reduction in ischemic strokes outweighs potential harm in increase in GI hemorrhage (covered only when prescribed by a health care provider) Contraceptive agents*† All FDA-approved contraceptive agents, excluding abortifacient agents, for all women with reproductive capacity as prescribed in writing by a Physician, Physician’s Assistant, or Nurse Practitioner within the legally appointed scope of his or her license (All generic contraceptives and all brand contraceptives that do not have a generic equivalent shall be covered at 100% with no co-payment. All brand contraceptives that do have a generic equivalent shall be covered at the co-payments stated in the Plan’s Schedule of Benefits.) Fluoride Chemoprevention of dental caries Supplements for children older than six months of age without fluoride in their water source Folic acid Supplements for women planning or capable of pregnancy containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid (covered only when prescribed by a health care provider) Gonorrhea ocular prophylaxis Prophylactic ocular topical medication for all newborns Immunization vaccines for adults Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza; Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; Varicella (doses, recommended ages and recommended populations vary) Immunization vaccines for children from birth to age 18 Diphtheria, Tetanus, Pertussis ; Haemophilus influenzae type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated Poliovirus; Influenza; Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; Varicela (doses, recommended ages, and recommended populations vary) Summary Information for Preventive Care Services without Cost Sharing Important: This summary lists all preventive care services required to be provided by non-grandfathered plans under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with the provisions of this summary, the provisions of this summary will supersede the terms of the Plan. Category Summary Required Preventive Care Services Applies only to non-grandfathered plans (Grandfathered status in Plan document) Covered In-Network Preventive Drugs, continued Service Iron supplementation Recommendation Supplements for children aged 6 to 12 months at risk for anemia (covered only when prescribed by a health care provider) *Non-grandfathered plans are required to provide coverage without cost sharing in the first Plan Year that begins on or after August 1, 2012. †Group health plans sponsored by certain religious employers are exempt from the requirement to cover contraceptive services. The definition of religious employer for purposes of the exemption is based solely on Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code, which primarily concerns churches and other houses of worship. A house of worship is not excluded from the exemption because it provides charitable social services to, or employs, persons of different religious faiths. Eligible nonexempt, nonprofit religious employers that object to contraceptive coverage on religious grounds are not required to provide contraceptive coverage under the plan. An eligible organization is one that (1) opposes providing coverage for some or all of any contraceptive services otherwise required to be covered, on account of religious objections; (2) is organized and operates as a nonprofit entity; (3) holds itself out as a religious organization; and (4) self-certifies that it meets these criteria in accordance with the provision of the final regulations. An eligible organization must provide a copy of its self-certification to the plan’s third-party administrator by the first plan year beginning on or after January 1, 2014. The third-party administrator must provide or arrange separate payments for contraceptive services for the women in the health plan of the organization at no cost to the women or to the organization. The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not specify the frequency, method, treatment, or setting for the provision of that service, the Plan can use reasonable medical management techniques (which generally limit or exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any coverage limitations under the Plan. Thus, to the extent not specified in a recommendation or guideline, a plan may rely on the relevant evidence base and these established techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. Plans retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost sharing for branded drugs if a generic version is available and is just as effective and safe. Revised_071113_Documentation Department