Preventive Services for 2012

Effective January 1, 2012, HealthChoice adopted new benefits for preventive services. This means certain preventive procedures are covered at 100% of Allowed Charges for our members who meet the clinical criteria. Members must use a HealthChoice Network Provider. When using a non-Network provider, these services are covered according to Plan benefits.

Please note: Procedure codes are subject to change.

	Preventive Service	Member Information	Provider Information
1.	Abdominal Aortic Aneurysm, Screening	One per calendar year for men, age 65 through 75, pre-Medicare Billing code: G0389	G0389, Male, Age 65 through 75, one free per calendar year, non-Medicare
2.	Alcohol Misuse Screening and Behavioral Counseling Interventions	Two total per calendar year for members and dependents age 18 and older Billing codes: 99408, 99409	99408, 99409, male and female, age 18 and greater, 2 free total per calendar year
3.	Aspirin for the Prevention of Cardiovascular Disease	Over-the-counter aspirin is covered for members and dependents age 45-79 Prescription required	Pharmacy Benefit Only: Over-the-counter aspirin covered for age 45-79 years, copay $0 Prescription required
4.	Asymptomatic Bacteriuria in Adults, Screening	One per calendar year for women age 18 and older with a pregnancy diagnosis Billing code: 81007	81007, female, age 18 and greater, pregnancy diagnosis, one free per calendar year
5.	Breast cancer, Screening	Age 40 and greater: refer to the Member Health Handbook for benefits	Age 40 and greater: refer to the Member Health Handbook for benefits
6.	Breast and Ovarian Cancer Susceptibility Genetic Risk Assessment and BRCA Mutation Testing (6a) Prophylactic chemo for women with breast cancer	One per calendar year for women age 18 and older Billing code: 96040 (6a) Handled on a case by case basis.	(6) 96040, female, age 18 and greater, one free per calendar year (6a) Handled on a case by case basis.
7.	Breastfeeding, Primary Care Interventions to Promote	Included in prenatal and postpartum care	Provided in prenatal and postpartum care
8.	Cervical Cancer, Screening	One per calendar year for women age 18 and older Billing codes: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0101	88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0101, One free total of the CPT/HCPCS codes per calendar year, age 18>, women
9.	Chlamydial Infection, Screening	One free per calendar year for women age 18 and older Billing code: 87110	87110 , female, age 18 and greater, one free per calendar year
10.	Colorectal Cancer, Screening	One total Fecal Occult Blood Test per calendar year for members and dependents Billing codes: 82270, 82271, 82272, 82274 One colon/sigmoidoscopy every three years for members and dependents age 50 through 75 with diagnosis codes V76.41 and V76.51. Billing codes: 45378, G0121, G0105 and any other CPT/HCPCS for colon/sigmoidoscopies	1.) FOBT: 82270, 82271, 82272, 82274, men and women, all ages, one total free per calendar year 2.) G0121, G0105 and any other CPT/HCPCS for colon/sigmoidoscopies (i.e., 45378, etc.), male and female, age 50 through 75, Diagnosis Code V76.41 and V76.51, one free every three years, this benefit is for the facility, anesthesia, radiology, and physician services.
11.	Congenital Hypothyroidism, Screening	One per calendar year for children up to age 1 Billing codes: 84443	84443, male and female, up to age 1, one free per calendar year
12.	Dental Caries in Preschool Children, Prevention	Pharmacy Benefit Only: Oral fluoride - all dosage forms for children through age 5 Prescription required.	Pharmacy Benefit Only: Oral fluoride - all dosage forms, prescription required, covered for those thru 5 years, copay $0
13.	Depression (Adults), Screening	One evaluation and management visit per calendar year for members and dependents age 18 and older with a primary diagnosis of depression	E&M, male and female, age 18 and greater, diagnosis code of depression in the primary diagnosis code field, one free per calendar year
14.	Diet, Behavioral Counseling in Primary Care to Promote a Healthy Diet	Any combination of the three billing codes for members and dependents age 18 and older. Maximum of three total per calendar year Billing codes: 97802, 97803, 97804	97802, 97803, 97804, male and female, age 18 and greater, any combination of these 3 CPT codes = 3 per calendar year total
15.	Gonorrhea, Screening	One screening code total per calendar year for women age 18 and older Billing codes: 87590, 87591, 87592	87590, 87591, 87592, female, age 18 and greater, one of the codes is free per calendar year
16.	Gonorrhea, Prophylactic Medication	Pharmacy Benefit Only: Erythromycin Opthalmic ointment for infants age one or younger	Pharmacy Benefit: Erythromycin Opthalmic ointment Member copay is $0, age one year or less
17.	Hearing Loss in Newborns, Screening	Included in office visit, age one or younger	Included in office visit, age 1 or younger
18.	Hepatitis B Virus Infection, Screening	One per calendar year for women age 18 and older with a diagnosis of pregnancy Billing code: 87340	87340, female, age 18 and greater, with a diagnosis of pregnancy, one free per calendar year
19.	High Blood Pressure, Screening	Included in the well child care visit for members and dependents age 18 and 19. Included in the preventive services visit for members and dependents age 20 and older	Included in the well child care visit for members and dependents age 18 and 19. Included in the preventive services visit for members and dependents age 20 and older
20.	HIV, Screening	One per calendar year for members and dependents age 12 and older Billing code: 86701	86701, male and female, age 12 and greater, one free per calendar year
21.	Iron Deficiency Anemia, Prevention	Pharmacy Benefit Only: Over-the-counter iron solution drops covered for infants less than age 1. This does not include the various baby formulas. Prescription required.	Pharmacy Benefit Only: Over-the-counter iron solution drops covered for infants less than age 1. This does not include the various baby formulas. Prescription required.
22.	Iron Deficiency Anemia, Screening	Included in prenatal services for pregnant women	Included in prenatal services for pregnant women
23.	Lipid Disorders in Adults, Screening	One per calendar year for members and dependents age 20 and older Billing code: 80061	80061, male and female, age 20 >, one free per calendar year
24.	Major Depressive Disorder in Children and Adolescents, Screening	One total per calendar year for any evaluation and management code for members and dependents age 12 through 17 with a primary diagnosis of major depression	Any E&M code, male and female, age 12 through 17, must have major depression diagnosis code in the primary diagnosis code field, one free per calendar year
25.	Obesity in Adults, Screening	One total per calendar year for any evaluation and management code for members and dependents age 18 and older with a diagnosis of morbid obesity Additional benefits are available in combination with the benefits available for Diet, Behavioral Counseling in Primary Care to Promote a Healthy Diet. Maximum of 3 total per calendar year. Billing codes: 97802, 97803, 97804	1.) Any E&M code, male and female, age 18 and greater, morbid obesity diagnosis, one free total per calendar year 2.) 97802, 97803, 97804, male and female, age 18 and greater, three total times regardless of diagnosis per calendar year. Reference #14 on this list as #14 and #25 are combined for the three codes maximum.
26.	Osteoporosis in Postmenopausal Women	One total per calendar year for women age 60 and older Billing codes: 77080, 77081	77080, 77081, female, age 60 and greater, one total free per calendar year
27.	Phenylketonuria, Screening	One per calendar year for infants up to age 1 Billing code: 84030	84030, male and female, up to age 1, free one time per calendar year
28.	Rh (D) Incompatibility, Screening	Two per calendar year for women Billing code: 86901	86901, female, all ages, two free per calendar year
29.	Sexually Transmitted Infections, Counseling	Three total per calendar year for members and dependents age 12 and older Billing code: 99412	99412, male and female, age 12 and greater, three total free per calendar year
30.	Sickle Cell Disease, Screening	One per calendar year for infants up to age 1 Billing code: 82489	82489, male and female, up to age 1, one free per calendar year
31.	Syphilis Infection, Screening	One total per calendar year for members and dependents age 18 and older Billing code: 86592, 86593	86592, 86593, male and female, age 18 and greater, only one of these CPT codes total per calendar year is free.
32.	Tobacco Use and Tobacco-Caused Disease, Counseling	One free per calendar year for members and dependents age 18 and older Billing code: 99406 Pharmacy Benefit Only: Tobacco cessation products, over-the-counter and prescription, for members and dependents age 18 and older. Prescription required. Limited to 2-90-day courses per year.	99406, male and female, age 18 and greater, one free per calendar year Pharmacy benefit only: Smoking Cessation for RX and over-the-counter is covered for 18 or older, copay $0. Prescription required. Limited to 2 - 90-day courses per year
33.	Type 2 Diabetes Mellitus in Adults, Screening	One every three years for members and dependents age 18 and older Billing code: 82947	82947, male and female, age 18 and greater, one free every 3 years
34.	Visual Impairment in Children Under Age 5, Screening	One total per calendar year for members and dependents through age 4 Billing codes: 99172, 99173	99172, 99173, male and female, up through the age of 4, only one total free per calendar year
35.	Folic Acid	Pharmacy Benefit Only: Over-the-counter folic acid supplement, 0.4 to 0.8 mg/day, for women through age 50 Prescription required	Pharmacy Benefit Only: Over-the-counter folic acid supplement, 0.4 to 0.8 mg/day, covered for females through 50 years, copay $0 Prescription required
36.	Childhood Obesity Screening and Interventions	One total per calendar year for members and dependents age 1 through 19 with a primary diagnosis of obesity Billing codes: 99383, 99384, 99385, 99393, 99394, 99395	99383, 99384, 99385, 99393, 99394, 99395, male and female age 1 through 19, primary diagnosis code of obesity, only one total free per calendar year
37.	Cover Pediatric Immunizations (according to ACIP Schedule)	Routine immunizations for children according to the current Centers for Disease Control and Prevention guidelines	Routine immunizations for children according to the current Centers for Disease Control and Prevention guidelines
38.	Adult Immunizations	Routine immunizations for adults according to the current Centers for Disease Control and Prevention guidelines	Routine immunizations for adults according to the current Centers for Disease Control and Prevention guidelines
39.	Pediatric Preventive Health Care "Bright Futures"	Children up to Age 20 Age 0 to 12 months, 8 visits Billing codes: 99381,99391 Age 1 year through 2 years, 4 visits per age Billing codes: 99382, 99392 Age 3 years through 5 years, 2 visits per age Billing codes: 99382,99383, 99392, 99393 Age 6 years through 11 years, 1 visit per age. Billing codes: 99383, 99393 Age 12 years through 17 years, 1 visit per age. Billing codes: 99384, 99394 Age 18 years through 19 years, 1 visit per age. Billing codes: 99385, 99395	Children up to Age 20 Age 0 to 12 months, 8 visits Billing codes: 99381,99391 Age 1 year through 2 years, 4 visits per age Billing codes: 99382, 99392 Age 3 years through 5 years, 2 visits per age Billing codes: 99382, 99383, 99392, 99393 Age 6 years through 11 years, 1 visit per age. Billing codes: 99383, 99393 Age 12 years through 17 years, 1 visit per age. Billing codes: 99384, 99394 Age 18 years through 19 years, 1 visit per age. Billing codes: 99385, 99395
40.	Adult Preventive Exam	One total per calendar year for members and dependents age 20 and over Billing codes: 99385, 99386, 99387, 99395, 99396, 99397	One total per calendar year for members and dependents age 20 and over Billing codes: 99385, 99386, 99387, 99395, 99396, 99397

Last Modified on 04/26/2012