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D E S I GN AT E D P R E V E N T I V E M E D I C A L S E R V I C E S
The following procedures are always considered preventive and covered at 100%
when they are administered by a doctor or health care provider in the network:
Routine cancer screenings
•
Computed tomographic (CT) colonography
•
Mammograms: A screening mammogram is considered a routine,
preventive service for women aged 40 (39) and over. Screening
mammograms for younger women who are judged to be at high risk by
their physician are covered under the medical benefits.
•
Prostate digital rectal examination (DRE)
Smoking cessation and services
•
Counseling visits: Services within this service category are limited to
8 combined visits per 12-month period
•
Smoking cessation treatment
•
Smoking cessation classes
Laboratory procedures
•
Newborn metabolic screening panel
•
Lab tests for gestational diabetes screening
Screening to reduce alcohol misuse
•
Alcohol and/or substance abuse screening during a physical examination
Radiology
•
Ultrasound b-scan and/or real time with image documentation for
abdominal aortic aneurysm (AAA) screening
Well woman exams
•
Annual gynecological examination
•
Preventive medicine services
•
Prenatal doctor’s office visits (does not include inpatient admissions, high
risk specialist visits, ultrasounds, amniocentesis, fetal stress tests, certain
diagnostic lab tests or delivery, including anesthesia)
•
Breast feeding support, supplies and counseling
Well adult exams
•
One exam per calendar year (vision and hearing exams are covered
once per calendar year)
Well child exams
•
Seven exams in the first 12 months of life
•
Three exams in the second 12 months of life
•
Three exams in the third 12 months of life
•
One exam every year thereafter
Immunizations
•
Diptheria, pertussis, tetanus (DPT)
•
Hepatitis A
•
Hepatitis B
•
Human papillomavirus (HPV): The HPV vaccination is covered for girls
and women 9 through 26 years of age.
•
Herpes zoster: The herpes zoster (shingles) vaccine is covered only for
people 60 years and older.
•
Influenza (flu)
•
Meningococcal (meningitis)
•
Measles, mumps, rubella (MMR)
•
Pneumococcal (pneumonia)
•
Varicella (chicken pox)
•
Rotavirus
•
Polio (IPV and OPV)
The following procedures can also be preventive; however certain exclusions and restrictions may apply. Consult your provider for further details.
General procedures
•
Barium enema
•
Cervical (Pap)
•
HPV screening
•
Prostate specific antigen (PSA)
•
Developmental testing exams
•
Endoscopy procedures: Colonoscopy and
sigmoidoscopy.
•
Osteoporosis screening (bone density test)
•
Electrocardiogram (EKG)
•
Counseling for a healthy diet
•
Obesity: Screening and counseling for adults
and children.
Laboratory procedures
•
Albumin
•
Bilirubin
•
Blood typing; Rh (D)
•
Calcium
•
Carbon cioxide (bicarbonate)
•
CBC
•
Chlamydia screening
•
Chloride
•
Cholesterol, lipid panel
•
Creatinine
•
Electrolyte panel
•
Fecal occult blood
•
Glucose
•
Gonorrhea screening
•
Hemoglobinopathy screenings
•
Hep B surface antigen
•
Hepatic function panel
•
HIV
•
Lead
•
Metabolic panel
•
Phosphatase, alkaline
•
Potassium
•
PPD (tuberculosis (TB) tine testing)
•
Protein, total
•
PTT
•
RPR/VDRL
•
Rubella serology
•
Sodium
•
Surgical pathology
•
Thyroid studies
•
Transferase, alanine amino (ALT)(SGPT)
•
Transferase, aspartate amino (AST)(SGOT)
•
Urea nitrogen (BUN)
•
Urine culture
•
Urinalysis
•
Venipuncture
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