Preventive Services for 2013 — Pre-Medicare Members Only

Effective January 1, 2013, the following benefits for preventive services will be covered at 100% of Allowed Charges for HealthChoice High, High Alternative, Basic, Basic Alternative, USA, and S-Account members who meet the clinical criteria and use a HealthChoice Network Provider.

Preventive Service		Member Information	Provider Information
1	Abdominal Aortic Aneurysm, Screening	One total per calendar year for men ages 65 through 75, pre-Medicare. Billing code: G0389	G0389, males ages 65 through 75; one total 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, males and females age 18 and older, two total free per calendar year.
3	Aspirin for the Prevention of Cardiovascular Disease	Over-the-counter aspirin is covered for members and dependents ages 45 through 79. Prescription required	Pharmacy Benefit Only — over-the-counter aspirin covered for ages 45 through 79, copay $0. Prescription required
4	Asymptomatic Bacteriuria in Adults, Screening	One total per calendar year for women age 18 and older with a pregnancy diagnosis. Billing code: 81007	81007, females age 18 and older with pregnancy diagnosis; one total free per calendar year.
5	Breast cancer, Screening	Age 40 and older; refer to the HealthChoice Health Handbook for benefits.	Age 40 and older; refer to the HealthChoice Health Handbook for benefits.
6	Breast and Ovarian Cancer Susceptibility	6) One total per calendar year for women age 18 and older. Billing code: 96040	6) 96040, females age 18 and older; one total free per calendar year.
6a	Genetic Risk Assessment and BRCA Mutation Testing Prophylactic chemo for women with breast cancer	6a) Handled on a case-by-case basis.	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 total 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 total free code per calendar year, females age 18 and older.
9	Chlamydial Infection, Screening	One total free per calendar year for women age 18 and older. Billing code: 87110	87110, females age 18 and older; one total 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 of all ages; one total free per calendar year. 2) G0121, G0105, and any other CPT/HCPCS for colon/sigmoidoscopies (i.e., 45378, etc.), males and females ages 50 through 75; diagnosis codes 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 one. Billing code: 84443	84443, males and females up to age one; one free per calendar year.
12	Dental Caries in Preschool Children, Prevention	Pharmacy Benefit Only — Oral fluoride, all dosage forms for children through age five. Prescription required.	Pharmacy Benefit Only — oral fluoride, all dosage forms; prescription required; covered for those through five years, copay $0.
13	Depression Screening (Adults)	One evaluation and management visit per calendar year for members and dependents age 18 and older with a primary diagnosis of depression.	E&M, males and females age 18 and older; 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, males and females age 18 and older; any combination of these three CPT codes; three total per calendar year.
15	Gonorrhea, Screening	One total screening code per calendar year for women age 18 and older. Billing codes: 87590, 87591, 87592	87590, 87591, 87592, females age 18 and older; one total free per calendar year.
16	Gonorrhea, Prophylactic Medication	Pharmacy Benefit Only — Erythromycin Ophthalmic ointment for infants age one or younger.	Pharmacy Benefit — Erythromycin Ophthalmic ointment; member copay is $0; age one year or younger.
17	Hearing Loss in Newborns, Screening	One total per calendar year, infants age one or younger. Billing codes: 92586, 92587	92586, 92587, age one or younger; one total free per calendar year.
18	Hepatitis B Virus Infection, Screening	One total per calendar year for women age 18 and older with a diagnosis of pregnancy. Billing code: 87340	87340, females age 18 and older with a diagnosis of pregnancy; one total free per calendar year.
19	High Blood Pressure, Screening	Included in the well child care visit for members and dependents ages 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 ages 18 and 19. Included in the preventive services visit for members and dependents age 20 and older.
20	HIV, Screening	One total per calendar year for members and dependents age 12 and older. Billing code: 86701	86701, males and females age 12 and older one total free per calendar year.
21	Iron Deficiency Anemia, Prevention	Pharmacy Benefit Only — over-the-counter iron solution drops covered for infants less than age one. 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 one. 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, males and females age 20 and older; 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 ages 12 through 17 with a primary diagnosis of major depression.	Any E&M code, males and females ages 12 through 17, must have major depression diagnosis code in the primary diagnosis code field; one total 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; three total per calendar year. Billing codes: 97802, 97803, 97804	1) Any E&M code, males and females age 18 and greater, morbid obesity diagnosis; one total free per calendar year. 2) 97802, 97803, 97804, male and female, age 18 and greater; three total, 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, females age 60 and older; one total free per calendar year.
27	Phenylketonuria, Screening	One per calendar year for infants up to age one. Billing code: 84030	84030, males and females up to age one; one total per calendar year.
28	Rh (D) Incompatibility, Screening	Two total per calendar year for women. Billing code: 86901	86901, females all ages; total 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, males and females age 12 and older; three total free per calendar year.
30	Sickle Cell Disease, Screening	One total per calendar year for infants up to age one. Billing code: 82489	82489, males and females up to age one; one free per calendar year.
31	Syphilis Infection, Screening	One total per calendar year for members and dependents age 18 and older. Billing codes: 86592, 86593	86592, 86593, males and females age 18 and older; one CPT code total free per calendar year.
32	Tobacco Use and Tobacco-Caused Disease, Counseling	One total 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; members and dependents age 18 and older. Prescription required. Limited to two 90-day courses per year.	99406, males and females age 18 and older; one total free per calendar year. Pharmacy benefit only — smoking cessation for RX and over-the-counter covered for 18 or older; copay $0. Prescription required. Limited to two 90-day courses per calendar 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, males and females age 18 and older; one total free every three years.
34	Visual Impairment in Children Under Age 5, Screening	One total per calendar year for members and dependents through age four. Billing codes: 99172, 99173	99172, 99173, males and females up through age four; 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; females through 50 years; copay $0. Prescription required.
36	Childhood Obesity Screening and Interventions	One total per calendar year for members and dependents ages 1 through 19 with a primary diagnosis of obesity. Billing codes: 99382, 99383, 99384, 99385, 99392, 99393, 99394, 99395	99382,99383, 99384, 99385, 99392, 99393, 99394, 99395, males and females ages 1 through 19, primary diagnosis code of obesity; 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. Immunization administration fee for members and dependents, age 18 and younger. Billing codes: 90460, 90461, 90471, 90472, 90472#, 90473, 90473#, 90474, 90474#, G8482, G8864, G8870, G0008, G0009, G0010	Routine immunizations for children according to the current Centers for Disease Control and Prevention guidelines.90460, 90461, 90471, 90472, 90472#, 90473, 90473#, 90474, 90474#, G8482, G8864, G8870, G0008, G0009, G0010, free immunization administration fee, males and females 18 or younger.
38	Adult Immunizations	Routine immunizations for adults according to the current Centers for Disease Control and Prevention guidelines. Immunization administration fee for members and dependents age 19 and older. Billing codes: 90471, 90472, 90472#, 90473, 90473#, 90474, 90474#, G8482, G8864, G8870, G0008, G0009, G0010	Routine immunizations for adults according to the current Centers for Disease Control and Prevention guidelines. 90471, 90472, 90472#, 90473, 90473#, 90474, 90474#, G8482, G8864, G8870, G0008, G0009, G0010, male and female, 19 and older; immunization administration fee.
39	Pediatric Preventive Health Care “Bright Futures”	Children up to age 20; additional benefit — all services on the same date of service as the preventive visit as described below with a preventive service V__ diagnosis code. Age 0 to 12 months; eight visits. Billing codes: 99381,99391 Age 1 year through 2 years; four visits per age. Billing codes: 99382, 99392 Age 3 years through 5 years; two visits per age. Billing codes: 99382,99383, 99392, 99393 Age 6 years through 11 years; one visit per age. Billing codes: 99383, 99393 Age 12 years through 17 years; one visit per age. Billing codes: 99384, 99394 Age 18 years through 19 years; one visit per age. Billing codes: 99385, 99395	Children up to age 20; additional benefit — all services on the same date of service as the preventive visit as described below with a preventive service V__ diagnosis code. Age 0 to 12 months; eight visits. Billing codes: 99381,99391 Age 1 year through 2 years; four visits per age. Billing codes: 99382, 99392 Age 3 years through 5 years; two visits per age. Billing codes: 99382,99383, 99392, 99393 Age 6 years through 11 years; one visit per age. Billing codes: 99383, 99393 Age 12 years through 17 years; one visit per age. Billing codes: 99384, 99394 Age 18 years through 19 years; one visit per age. Billing codes: 99385, 99395
40	Adult Preventive Exam	One total per calendar year for members and dependents age 20 and older. Billing codes: 99385, 99386, 99387, 99395, 99396, 99397	One total per calendar year; age 20 and older. Billing codes: 99385, 99386, 99387, 99395, 99396, 99397
41	Well Woman Visit	Age 18 through 19, refer to Pediatric Preventive Health Care “Bright Futures,” 39 above. Age 20 and older, refer to adult preventive exam, 40 above.	Age 18 through 19, refer to Pediatric Preventive Health Care “Bright Futures,” 39 above. Age 20 and older, refer to adult preventive exam, 40 above.
42	Screening for Gestational Diabetes	Two total per calendar year for female members and dependents with a diagnosis of pregnancy. Billing codes: 82947, 82948, 82950, 82951, 82952, 83036	82947, 82948, 82950, 82951, 82952, 83036, female members and dependents with a diagnosis of pregnancy; two total free per calendar year.
43	Human Papillomavirus Testing	One total every three calendar years for female members and dependents. Billing codes: 87620, 87621, 87622	87620, 87621, 87622, female members and dependents; one total free every three calendar years.
44	Counseling for Sexually Transmitted Infections	Refer to preventive benefit 29 above.	Refer to preventive benefit 29 above.
45	Counseling for Screening for Human Immune-Deficiency Virus	Refer to preventive benefit 29 above.	Refer to preventive benefit 29 above.
46	Breastfeeding, Support, Supplies and Counseling	Two total per calendar year for female members and dependents with a diagnosis of pregnancy. Billing codes: 99241, 99242, 99243, 99244, 99245, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99351, S9443 Breast pumps: female members and dependents; one total per lifetime. Billing codes: E0602NU, E0602RR, E0603, E0604 Supplies: female members and dependents, one each per pregnancy. Billing codes: A4281, A4282, A4283, A4284, A4285, A4286	99241, 99242, 99243, 99244, 99245, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99351, S9443, female members and dependents with a pregnancy diagnosis, two total free per calendar year. E0602NU, E0602RR, E0603, E0604, female members and dependents; one total free per lifetime. A4281, A4282, A4283, A4284, A4285, A4286, female members and dependents, one each pregnancy.
47	Screening and Counseling for Interpersonal and Domestic Violence	Refer to preventive benefit 40 above.	Refer to preventive benefit 40 above.
48	Contraceptive Methods and Counseling	IUD — insertion and removal, one total every five calendar years, female members and dependents age 18 and older. Billing codes: 11981, 11976, 11982, 11983, 58300, 58301, 81025, J7300, J7302, S4981, S4989 Tubal ligation — one total per lifetime, female members and dependents age 18 and older; independent tubal ligations include the facility, anesthesia, radiology, and physician services. Tubal ligations billed in conjunction with a different surgery billed by the surgeon only, will be subject to ACA preventive benefits only. Billing codes: 58565, 58600, 58670, 58671, 81025, A4264 Pharmacy benefits only — diaphragm, cervical cap, oral contraceptives, patch, vaginal contraceptive ring, Ella, female, prescription required. Single source and generic as prescribed. Females 16 and under, Plan B prescription required.	11981, 11976, 11982, 11983, 58300, 58301, 81025, J7300, J7302, S4981, S4989, female members and dependents age 18 or older, one free IUD total every five calendar years. 58565, 58600, 58670, 58671, 81025, A4264, female members and dependents age 18 and older receive one total free per lifetime; independent tubal ligations include the facility, anesthesia, radiology, and physician services. Tubal ligations billed in conjunction with a different surgery billed by the surgeon only, will be subject to ACA preventive benefits only. Pharmacy benefits only — diaphragm, cervical cap, oral contraceptives, patch, vaginal contraceptive ring, Ella, female, prescription required. Single source and generic as prescribed. Plan B, female age 16 and under, prescription required.

Last Modified on 01/17/2013