Schedule of Covered Preventative Services Only for Non-Grandfathered Plans

THE FOLLOWING BENEFITS ARE ONLY PROVIDED IN-NETWORK.  NO BENEFITS ARE PROVIDED OUT-OF-NETWORK.  WHEN THESE SERVICES ARE PROVIDED IN-NETWORK, THEY ARE PROVIDED 100% AND ARE NOT SUBJECT TO DEDUCTIBLES OR CO-PAYS

Covered Preventive Services for Children

·        Alcohol and Drug Use assessments for adolescents

·        Autism screening for children at 18 and 24 months

·        Behavioral assessments for children of all ages

·        Cervical Dysplasia screening for sexually active females

·        Congenital Hypothyroidism screening for newborns

·        Developmental screening for children under age 3, and surveillance throughout childhood

·        Dyslipidemia screening for children at higher risk of lipid disorders

·        Fluoride Chemoprevention supplements for children without fluoride in their water source

·        Gonorrhea preventive medication for the eyes of all newborns

·        Hearing screening for all newborns

·        Height, Weight and Body Mass Index measurements for children

·        Hematocrit or Hemoglobin screening for children

·        Hemoglobinopathies or sickle cell screening for newborns

·        HIV screening for adolescents at higher risk

·        Immunization vaccines for children from birth to age 18 —

        doses, recommended ages, and recommended populations vary:

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

·        Iron supplements for children ages 6 to 12 months at risk for anemia

·        Lead screening for children at risk of exposure

·        Medical History for all children throughout development

·        Obesity screening and counseling

·        Oral Health risk assessment for young children

·        Phenylketonuria (PKU) screening for this genetic disorder in newborns

·        Sexually Transmitted Infection (STI) prevention counseling for adolescents at higher risk

·        Tuberculin testing for children at higher risk of tuberculosis

·        Vision screening for all children

       Covered Preventive Services for Women, Including Pregnant Women

·     Anemia screening on a routine basis for pregnant women

·     Bacteriuria urinary tract or other infection screening for pregnant women

·     BRCA counseling about genetic testing for women at higher risk

·     Breast Cancer Mammography screenings every 1 to 2 years for women over 40

·     Breast Cancer Chemoprevention counseling for women at higher risk

·     Breast Feeding interventions to support and promote breast feeding

·     Cervical Cancer screening for sexually active women

·     Chlamydia Infection screening for younger women and women at higher risk

·     Folic Acid supplements for women who may become pregnant

·     Gonorrhea screening for all women at higher risk

·     Hepatitis B screening for pregnant women at their first prenatal visit

·     Osteoporosis screening for women over age 60 depending on risk factors

·     Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

·     Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

·     Syphilis screening for all pregnant women or other women at increased risk

      Covered Preventive Services for Adults

·     Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

·     Alcohol Misuse screening and counseling

·     Aspirin use for men and women of certain ages

·     Blood Pressure screening for all adults

·     Cholesterol screening for adults of certain ages or at higher risk

·     Colorectal Cancer screening for adults over 50

·     Depression screening for adults

·     Type 2 Diabetes screening for adults with high blood pressure

·     Diet counseling for adults at higher risk for chronic disease

·     HIV screening for all adults at higher risk

·     Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:

o  Hepatitis A

o  Hepatitis B

o  Herpes Zoster

o  Human Papillomavirus

o  Influenza

o  Measles, Mumps, Rubella

o  Meningococcal

o  Pneumococcal

o  Tetanus, Diphtheria, Pertussis

o  Varicella

·     Obesity screening and counseling for all adults

·     Sexually Transmitted Infection (STD prevention counseling for adults at higher risk

·     Tobacco Use screening for all adults and cessation interventions for tobacco users

·     Syphilis screening for all adults at higher risk