Preventive Services Collection of venous blood by venipuncture Collection of capillary blood specimen (e.g., finger, heel, ear stick)

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1 Preventive Services Due to the Patient Protection and Affordable Care Act (commonly referred to as federal health care reform), with the exception of groups maintaining "grandfathered" status, all Tufts Health Plan plans are required to provide 100% coverage for preventive care services. Grandfathered groups are not subject to this requirement, but many of these groups have opted to cover preventive services with no cost sharing. This means that members will have no cost sharing responsibility when preventive services are rendered by an innetwork provider. Members may still be required to pay a copayment, deductible or coinsurance for preventive services received from out-of-network providers (PPO and POS plans), or for non-preventive services received in conjunction with a preventive services visit. Preventive services identified in this policy are based on recommendations from the U.S. Preventive Services Task Force, Bright Futures, American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and Advisory Committee for Immunization Practices (ACIP). Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services Task Force List that have an A or B rating. The American Medical Association created this modifier to allow providers to identify a preventive service for which patient cost sharing does not apply under the Patient Protection and Affordable Care Act, which prohibits patient cost sharing for non-grandfathered plans. Modifier 33 is appropriate to use with a CPT code that is a diagnostic/treatment service being performed as a preventive service. Refer to the Modifier Payment Policy for more information regarding modifiers. Tufts Health Plan covers the women s preventive health care services as indicated in the Woman s Health section of this document, with no cost share for most members when those services are rendered by a provider in the member s plan network. Please refer to the Woman s Health section of this document for additional information. Providers and their office staff are required to use self-service channels to verify effective dates and copayments for commercial members prior to initiating services. VENIPUNCTURE The below CPT codes are considered preventive when billed with Modifier 33 and/or when billed with one of the below ICD-9 or ICD-10 codes: Collection of venous blood by venipuncture Collection of capillary blood specimen (e.g., finger, heel, ear stick) ICD-9 Diagnosis Code V20.2 Routine infant or child health check V20.31 Health supervision for newborn under 8 days old V20.32 Health supervision for newborn 8 to 28 days old V22.0 Supervision of normal pregnancy V22.1 Supervision of other than normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of labor pre-term V23.42 Pregnancy with history of ectopic pregnancy V23.49 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida Revised 07/16/ Preventive Services

2 ICD-9 Diagnosis Code V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in-utero procedure during previous pregnancy V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy V25.2 Sterilization V70.0 Routine general medical examination at a health care facility V72.62 Laboratory examination ordered as part of a routine general medical examination V77.1 Diabetes mellitus V77.91 Screening for lipid disorders The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-9 Diagnosis Code O O09.93 Supervision of high risk pregnancy Z00.00 Encounter for general adult medical examination without abnormal findings Z Health examination for newborn under 8 days old Z Health examination for newborn 8 to 28 days old Z Encounter for routine child health examination without abnormal findings Z13.1 Encounter for screening for diabetes mellitus Z Encounter for screening for lipoid disorders Z30.2 Encounter for sterilization Z33.1 Pregnant state, incidental Z Z34.93 Encounter for supervision of normal pregnancy PREVENTIVE OFFICE VISITS The below CPT codes are considered preventive: interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) interventions, and the ordering of laboratory/diagnostic procedures, new patient; years interventions, and the ordering of laboratory/diagnostic procedures, new patient; years Revised 07/16/ Preventive Services

3 99387 interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older age interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; years age interventions, and the ordering of laboratory/diagnostic procedures, established patient; years age interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center Subsequent hospital care, per day, for evaluation and management of normal newborn Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit ROUTINE HEALTH SCREENINGS: ADULT Abdominal Aortic Aneurysm: Men ages The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V15.82 (Personal history of tobacco use, presenting hazards to health), V81.2 (Screening for other and unspecified cardiovascular conditions) or ICD-10 codes Z13.6 (Encounter for screening for cardiovascular disorders), Z Patient Protection and Affordable Care Act CPT/HCPCS Code Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited G0389 Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening Revised 07/16/ Preventive Services

4 Asymptomatic Bacteriuria, Rh (D) Blood Typing (first pregnancy related visit), Iron Deficiency Anemia Pregnant Women CPT codes (Urinalysis), (Blood typing; Rh (D)), (Blood count; complete) and (Blood count; complete) are considered preventive when billed with one of the below ICD-9 or ICD-10 diagnosis codes: ICD-9 Diagnosis Code V22.0 Supervision of normal pregnancy V22.1 Supervision of other than normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of labor pre-term V23.42 Pregnancy with history of ectopic pregnancy V23.49 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in-utero procedure during previous pregnancy V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code O O09.93 Supervision of high risk pregnancy Z33.1 Pregnant state, incidental Z Z34.93 Encounter for supervision of normal pregnancy Blood Pressure Screening: Adults ages 18 and older Included in preventive evaluation and management visit BRCA Genetic Testing* The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V10.3 (Personal history of malignant neoplasm, breast), V16.3 (Family history of malignant neoplasm, breast) or V16.41 (Family history of malignant neoplasm, genital organs, ovary) or ICD-10 codes Z80.3 (Family history of malignant neoplasm of breast), Z80.41 (Family history of malignant neoplasm of ovary), or Z85.3 (Personal history of malignant neoplasm of breast): CPT/HCPCS Code BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants Revised 07/16/ Preventive Services

5 CPT/HCPCS Code BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant *Prior Authorization is required for BRCA Genetic Testing. Please refer to our Medical Necessity Guidelines. Breast Cancer: Screening with Mammography ages 40 and older The below CPT/HCPCS codes are considered preventive: CPT/HCPCS Code Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images Screening mammography, bilateral (2-view film study of each breast) G0202 Screening mammography, producing direct digital image, bilateral, all views Cervical Cancer The below CPT/HCPCS codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: CPT/HCPCS Code Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision Cytopathology, cervical or vaginal (any reporting system) Cytopathology smears, cervical or vaginal; screening by automated system Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening Cytopathology, slides, cervical or vaginal; manual screening Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening Cytopathology, slides, cervical or vaginal; with manual screening and rescreening Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician G0141 Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician Revised 07/16/ Preventive Services

6 CPT/HCPCS Code G0143 G0144 G0145 G0147 G0148 P3000 P3001 Q0091 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening Screening cytopathology smears, cervical or vaginal, performed by automated system Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory ICD-9 Diagnosis Code V72.31 Routine gynecological examination V76.2 Screening for malignant neoplasm of the cervix The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Z Encounter for gynecological examination (general) (routine) with abnormal findings Z Encounter for gynecological examination (general) (routine) without abnormal findings Z12.4 Encounter for screening for malignant neoplasm of cervix Chlamydia and Gonorrhea: Women age 24 & younger or 25 & older at increased risk The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission): Culture, chlamydia, any source Infectious agent antigen detection by immunofluorescent technique Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method Infectious agent detection by nucleic acid (DNA or RNA); direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); quantification Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Colorectal Cancer: Adults ages The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V76.51 (Special screening for malignant neoplasms, colon), V16.0 (Family history of malignant neoplasm, Gastrointestinal tract) or ICD-10 code Z12.11 (Encounter for screening for malignant neoplasm of colon), Z80.0 (Family history of malignant neoplasm of digestive organs): CPT/HCPCS Code Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Revised 07/16/ Preventive Services

7 CPT/HCPCS Code Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing Sigmoidoscopy, flexible; with biopsy, single or multiple Sigmoidoscopy, flexible; with removal of foreign body Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance Sigmoidoscopy, flexible; with decompression of volvulus, any method Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed) Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Computed tomographic (CT) colonography, screening, including image postprocessing Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122 Colorectal cancer screening; barium enema G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations G0464 Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3) Revised 07/16/ Preventive Services

8 CPT/HCPCS Code G6022 G6024 S3890 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesions(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, flexible; proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique DNA analysis, fecal, for colorectal cancer screening Depression: Adults ages 18 and older The below CPT/HCPCS codes are considered preventive: G0444 interventions, and the ordering of laboratory/diagnostic procedures, new patient; years interventions, and the ordering of laboratory/diagnostic procedures, new patient; years interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older age interventions, and the ordering of laboratory/diagnostic procedures, established patient; years age interventions, and the ordering of laboratory/diagnostic procedures, established patient; years age interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Annual depression screening, 15 minutes Hepatitis B Virus: Persons at High Risk The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: Hepatitis B core antibody (HBcAb); total Hepatitis B surface antibody (HBsAb) Hepatitis Be antibody (HBeAb) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) ICD-9 Diagnosis Code V20.2 Routine infant or child health check (over 28 days of age) V22.0 Supervision of normal pregnancy V22.1 Supervision of other than normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of labor pre-term V23.42 Pregnancy with history of ectopic pregnancy V23.49 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history Revised 07/16/ Preventive Services

9 ICD-9 Diagnosis Code V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in-utero procedure during previous pregnancy V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy V70.0 Routine general medical examination at a health care facility V73.89 Other specified viral diseases V74.5 Special screening examination for bacterial and spirochetal diseases, Venereal disease The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code O O09.93 Supervision of high risk pregnancy Z00.00 Encounter for general adult medical examination without abnormal findings Z Encounter for routine child health examination without abnormal findings Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.59 Encounter for screening for other viral diseases Z33.1 Pregnant state, incidental Z Z34.93 Encounter for supervision of normal pregnancy Hepatitis C Virus: Persons at high risk for infection or a one-time screening for adults born between 1945 and 1965 The below CPT /HCPCS codes are considered preventive: Hepatitis C antibody G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) HIV: Adolescents and adults at increased risk and Pregnant Women HIV screenings should be performed in adolescents and adults ages Younger adolescents and older adults should be screened if they're at a higher risk. The below CPT codes are considered preventive: Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Antibody; HIV Antibody; HIV Antibody; HIV-1 and HIV-2, single assay Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 Lipid Disorders in Adults: Men ages 35 and older, Men ages with an increased risk for coronary heart disease (CHD), Women ages 45 and older, and Women ages with an increased risk for CHD The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for lipoid disorders) or ICD-10 code Z (Encounter for screening for lipoid disorders): Lipid panel Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Revised 07/16/ Preventive Services

10 83719 Lipoprotein, direct measurement; VLDL cholesterol Lipoprotein, direct measurement; LDL cholesterol Triglycerides Lung Cancer Screening: Adults ages 55 to 80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V15.82 (History of tobacco use) or V76.0 (Special screening for malignant neoplasms, respiratory organs) or ICD-10 code Z (Personal history of nicotine dependence) or Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs): CPT/HCPCS Code Computed tomography, thorax; without contrast material S8032 Low-dose computed tomography for lung cancer screening S8092 Electron beam computed tomography (also known as Ultrafast CT, Cine CT) Obesity Screening: Adults The below CPT codes are considered preventive: Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Osteoporosis: Postmenopausal Women ages 65 and older with no risk factors or ages 60 and older with risk factors The below CPT codes are considered preventive when billed one of the following - ICD-9 code V17.81 (Family history of, osteoporosis), V82.81 (Special screening for osteoporosis) or ICD-10 codes Z (Encounter for screening for osteoporosis), Z82.62 (Family history of osteoporosis): Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Revised 07/16/ Preventive Services

11 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) Screening for Gonorrhea and Syphilis (Pregnant Women) The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: Syphilis test, non-treponemal antibody; qualitative Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae ICD-9 Diagnosis Code V22.0 Supervision of normal pregnancy V22.1 Supervision of other than normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of labor pre-term V23.42 Pregnancy with history of ectopic pregnancy V23.49 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in-utero procedure during previous pregnancy V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code O O09.93 Supervision of high risk pregnancy Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z33.1 Pregnant state, incidental Z Z34.93 Encounter for supervision of normal pregnancy Revised 07/16/ Preventive Services

12 Sexually Transmitted Infections (STI) Screening The below CPT codes are considered preventive: Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Syphilis test, non-treponemal antibody; qualitative Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Antibody; HIV Antibody; HIV Antibody; HIV-1 and HIV-2, single assay Syphilis: Men and Women at increased risk The below CPT code is considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission): Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) Type 2 Diabetes Mellitus: Men and Women - Sustained BP 135/80+ The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.1 (Screening for diabetes mellitus) or ICD-10 code Z13.1 (Encounter for screening for diabetes mellitus): Glucose; quantitative, blood (except reagent strip) Glucose; blood, reagent strip ROUTINE HEALTH SCREENINGS: PEDIATRIC Application of Fluoride Varnish: Infants and children The below CPT code is considered preventive when billed with one of the following - ICD-9 code V20.2 (Routine infant or child health check) or ICD-10 code Z (Encounter for routine child health examination with abnormal findings) and Z (Encounter for routine child health examination without abnormal findings): Application of topical fluoride varnish by a physician or other qualified health care professional Congenital Hypothyroidism Screening: Newborns Included in inpatient evaluation and management services for newborns Depression: Adolescents ages The below CPT/HCPCS codes are considered preventive: G0444 interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Annual depression screening, 15 minutes Revised 07/16/ Preventive Services

13 Developmental/Behavioral Assessment The below CPT code is considered preventive: Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report The below CPT code is considered preventive when billed with one of the following - ICD-9 code V20.2 (Routine infant or child health check (over 28 days of age)) or ICD-10 code Z (Encounter for routine child health examination without abnormal findings): G0451 Developmental testing, with interpretation and report, per standardized instrument form Dyslipidemia The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for lipoid disorders) or ICD-10 code Z (Encounter for screening for lipoid disorders): Lipid panel Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Lipoprotein, direct measurement; VLDL cholesterol Lipoprotein, direct measurement; LDL cholesterol Triglycerides Hearing Screening The below CPT codes are considered preventive or when billed with one of the below ICD-9 or ICD-10 codes: Screening test, pure tone, air only Pure tone audiometry (threshold); air only Tympanometry (impedance testing) Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report ICD-9 Diagnosis Code V20.2 Routine infant or child health check (over 28 days of age) V30.00 Single liveborn, born in hospital, delivered w/o mention of cesarean delivery V30.01 Single liveborn, born in hospital, delivered by cesarean delivery V30.1 Single liveborn, born before admission to hospital V30.2 Single liveborn, born outside of hospital and not hospitalized V31.00 Twin, mate liveborn, born in hospital, delivered w/o mention of cesarean delivery V31.01 Twin, mate liveborn, born in hospital, delivered by cesarean delivery V31.1 Twin, mate liveborn, born before admission to hospital V31.2 Twin, mate liveborn, born outside of hospital and not hospitalized V34.00 Other multiples, all liveborn, born in hospital, delivered w/o mention of cesarean delivery V34.01 Other multiples, all liveborn, born in hospital, delivered by cesarean delivery V34.1 Other multiples, all liveborn, born before admission to hospital Revised 07/16/ Preventive Services

14 ICD-9 Diagnosis Code V34.2 Other multiples, all liveborn, born outside of hospital and not hospitalized V72.19 Examination of ears and hearing The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Z Encounter for routine child health examination without abnormal findings Z01.10 Encounter for examination of ears and hearing without abnormal findings Z38.00 Z38.8 Liveborn infants according to place of birth and type of delivery Hemocrit or Hemoglobin The below CPT codes are considered preventive: Blood count; hematocrit Blood count; hemoglobin Blood count; spun microhematocrit Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Lead The below CPT code is considered preventive when billed with one of the following - ICD-9 code V82.5 (Screening for chemical poisoning and other contamination) or ICD-10 code Z13.88 (Encounter for screening for disorder due to exposure to contaminants): Lead Metabolic/Hemoglobin Screening: Newborns The below CPT codes are considered preventive: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood count; hemoglobin Blood count; spun microhematocrit Obesity Screening: Children and Adolescents ages 6-17 The below CPT codes are considered preventive: interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Revised 07/16/ Preventive Services

15 99394 age interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Phenylketonuria Screening: Newborns Included in inpatient evaluation and management services for newborns Screening/Risk Assessment The below CPT code is considered preventive: Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal) Skin Cancer Behavioral Counseling: Children, Adolescents and Young Adults ages 10 to 24 Included in preventive evaluation and management visit Tuberculin Test The below CPT codes are considered preventive: Skin test; tuberculosis, intradermal Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response Visual Acuity Screening The below CPT code is considered preventive when billed with one of the following - ICD-9 code V20.2 (Routine infant or child health check (over 28 days of age) or ICD-10 code Z (Encounter for routine child health examination without abnormal findings): Screening test of visual acuity, quantitative, bilateral Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral Visual Impairment: Children younger than 5 The below CPT codes are considered preventive: interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) age interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Revised 07/16/ Preventive Services

16 PREVENTIVE IMMUNIZATIONS All immunizations are subject to availability. Refer to our List of Unavailable Vaccines and Drugs policy for additional information. Pediatric and Adolescent Immunizations The below pediatric and adolescent immunizations are considered preventive: Immunization/Vaccine Anthrax Anthrax vaccine, for subcutaneous or intramuscular BCG Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use DTP Haemophilus Influenza Type B Hepatitis A Hepatitis B Diphtheria, tetanus toxoids, and acellular pertussis vaccine, Haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use Diphtheria toxoid, for intramuscular use Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Haemophilus influenza B vaccine (DTP-Hib), for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Haemophilus influenza B vaccine (DtaP-Hib), for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use Haemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use Haemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use Haemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use Haemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 does schedule), for intramuscular use Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Revised 07/16/ Preventive Services

17 Immunization/Vaccine Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use Hepatitis B and Haemophilus influenza b vaccine (Hep- B-Hib), for intramuscular use Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use HPV: ages Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use Inactivated Poliovirus Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA) Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL) Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN) Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use Influenza virus vaccine, split virus, preservative-free, for intradermal use Influenza virus vaccine, split virus, preservative-free, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, preservative-free, when administered to individuals 3 years and older, for intramuscular use Influenza Influenza virus vaccine, split virus, when administered to children months of age, for intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, live, for intranasal use Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Influenza virus vaccine, pandemic formulation, live, for intranasal use Influenza virus vaccine, quadrivalent, live, for intranasal use Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use Revised 07/16/ Preventive Services

18 Immunization/Vaccine Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use Japanese Encephalitis Japanese encephalitis virus vaccine, for subcutaneous use Japanese encephalitis virus vaccine, inactivated, for intramuscular use Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for intramuscular use Meningococcal Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4-dose schedule, when administered to children 2-15 months of age, for intramuscular use Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use Mumps virus vaccine, live, for subcutaneous use Measles virus vaccine, live, for subcutaneous use MMR (Measles, Mumps, Rubella) Rubella virus vaccine, live, for subcutaneous use Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use MMRV (Measles, mumps, rubella, and varicella) Rabies Rotavirus Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Rabies vaccine, for intramuscular use Rabies vaccine, for intradermal use Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use Tetanus Tetanus toxoid adsorbed, for intramuscular use Typhoid vaccine, live, oral, Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use, Typhoid Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use, Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military) Varicella Varicella virus vaccine, live, for subcutaneous use Yellow Fever Yellow fever vaccine, live, for subcutaneous use Adult Immunizations The following adult immunizations are considered preventive: Immunization/Vaccine Anthrax Anthrax vaccine, for subcutaneous or intramuscular BCG Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular DTP use Diphtheria, tetanus toxoids, and acellular pertussis vaccine, Haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use Revised 07/16/ Preventive Services

19 Immunization/Vaccine Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use Tetanus and diphtheria toxoids (Td) adsorbed when administered to individuals 7 years or older, for intramuscular use Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Haemophilus influenza B vaccine (DTP-Hib), for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Haemophilus influenza B vaccine (DtaP-Hib), for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use Hepatitis A Hepatitis A vaccine, adult dosage, for intramuscular use Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 does schedule), for intramuscular use Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use Hepatitis B and Haemophilus influenza b vaccine (Hep- B-Hib), for intramuscular use Hepatitis A and B Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use HPV: ages Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use Influenza virus vaccine, split virus, preservative-free, for intradermal use Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, live, for intranasal use Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use Influenza Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Influenza virus vaccine, quadrivalent, live, for intranasal use Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA) Revised 07/16/ Preventive Services

20 Immunization/Vaccine Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL) Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN) Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Japanese Encephalitis Japanese encephalitis virus vaccine, for subcutaneous use Japanese encephalitis virus vaccine, inactivated, for intramuscular use Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular Meningococcal Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for intramuscular use Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use MMR (Measles, Mumps, Rubella) MMRV (Measles, mumps, rubella, and varicella) Mumps virus vaccine, live, for subcutaneous use Measles virus vaccine, live, for subcutaneous use Rubella virus vaccine, live, for subcutaneous use Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Pneumococcal (polysaccharide) Rabies Pneumococcal conjugate vaccine, 7 valent, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Rabies vaccine, for intramuscular use Rabies vaccine, for intradermal use Tetanus Tetanus toxoid adsorbed, for intramuscular use Typhoid vaccine, live, oral, Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use, Typhoid Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use, Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military) Varicella Varicella virus vaccine, live, for subcutaneous use Zoster Zoster (shingles) vaccine, live, for subcutaneous injection Yellow Fever Yellow fever vaccine, live, for subcutaneous use Revised 07/16/ Preventive Services