Preventive Care Services Summary

Preventive Care Services Summary Below is a list of preventive services along with the diagnoses and procedure codes that Community Health Options has determined to meet or exceed the requirements and recommendations issued by the Affordable Care Act (ACA) as of the date this was last updated. This document will be updated periodically to reflect the most up-to-date requirements. Services may be subject to Prior Approval or other Medical Management criteria. Preventive Health Services for Adults Abdominal Aortic Aneurysm Screening Alcohol Misuse screening and counseling Aspirin use to prevent cardiovascular disease 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 Males only (with any history of smoking) 76770, 76775, G0389 Z87891, Z0000, Z0001 1 PER LIFETIME Ages 65-75 years One in a lifetime Age 18 and over 99408, 99409 Z0000, Z0001, Z1389 N/A N/A N/A Age 18 and over 80061, 82465, 83718, 83719, 83721, 84478 Z0000, Z0001, Z13220 All men age 35 and older Men ages 20 to 35 who have heart disease or risk factors for heart disease Women age 20 and older who have heart disease or risk factors for heart disease 50 and over 00810, 44388, 44389, 44392, 44393, 44394, 45300, 45305, 45308, 45309, 45315, 45320, 45330, 45331, 45332, 45333, 45338, 45339, 45341, 45342, 45378, 45380, 45381, 45383, 45384, 45385, 82270, 82272, 82274, 88304, 88305, G0104, G0105, G0106, G0120, G0121, G0122, G0328, G0464 Age 18 and over G0444 99420 Z0000, Z0001, Z120, Z1210, Z1211, Z1212, Z1213, Z1279, Z1289, Z129, Z800, Z809, Z8371, Z8379, Z8500, Z85038, Z85048, Z86010 Z1389 Revised 08/22/2016 1

Adults Diabetes (Type 2) screening for adults with high blood pressure Diet counseling for adults at higher risk for chronic disease HIV screening for everyone ages 15 to 65, and other ages at increased risk Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: 82947, 82948, 82950, 82951, 82952, 83036 O24410, O24414, O24419, O24420, O24424, O24429, O24430, O24434, O24439, O99810, O99814, O99815, Z131 97802, 97803, 97804, G0270, G0271, Z724 S9470, 99401, 99403, 99404 86689, 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, G0432, G0433, G0435 90460, 90461, 90471, 90472, 90473, 90474 Hepatitis A 90632, 90633, 90634, 90636 Hepatitis B 90645, 90646, 90647, 90648 Herpes Zoster 90736 Human Papillomavirus 90649, 90650 Influenza (Flu Shot) 90654-90664, 90685-90686 Measles, Mumps, Rubella 90704-90710 Meningococcal 90644, 90733, 90734 Pneumococcal 90669, 90670 Tetanus, Diphtheria, Pertussis 90696-90703, 90714, 90715, 90719-90723 Varicella 90716 Obesity screening and counseling for all adults Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Syphilis screening for all adults at higher risk 97802-97804 Z0000, Z0001, Z00121, Z00129, Z1389 99401-99404, G0445 86592, 86593 O0900, O0901, O0902, O0903, O0910, O0993, Z112, Z113, Z331, Z3400, Z3401, Z3402, Z3403, Z3480, Z3481, Revised 08/22/2016 2

Z3482, Z3483, Z3490, Z3491, Z3492, Z3493 Preventive Health Services for Adults Tobacco Use screening for all 99406, 99407, G0436, G0437 adults and cessation interventions for tobacco users Lung Cancer Screening Ages 55-80 G0297, S8032 F17210, F17211, F17213, F17218, F17219, Z87891 Preventive Health Services for Women Anemia screening on a routine basis for pregnant women Pregnant females 85014, 85018 O0900, O0901, O0902, O0903, O0910, Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer Breast Cancer Mammography screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention counseling for women at higher risk Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer screening for sexually active women Females 81211-81217 Z0000, Z0001, Z1501, Z803, Z8041, Z8049, Z8543 40 and over - ME 35 and over NH Females E/M CODE 99201-99215, 99385-99387, 99395-99397 G0202, 77052, 77057, 77063 1 per year Z803, Z8041 Females S9443, E0603, E0604, A4281-A4286, 99502 Z391 Females 88141-88175, 87620-87621, 87623, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, Q0091 Z0000, Z0001, Z01411, Z01419, Z0142, Z1151, Z124 Revised 08/22/2016 3

Women Chlamydia Infection screening for younger women and other women at higher risk Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt religious employers. Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may become pregnant Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea screening for all women at higher risk Females 86631, 86632, 87110, 87270, 87320, 87485-87487, 87490-87492 Females Sterilization - 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264 Contraceptives - 57170, A4261, A4266, J7297, J7298, J7300, J7301, J7307, J1050, 11976, 58300, 58301, S4981, S4989 Anesthesia - 00851, 00940, 00942, 00950, 00952, 01960, 01961, 01965, 01966, 01967, 01968 Females COVERED UNDER E/M Females Pharmacy Vendor Z0000, Z0001, Z118 Z30011, Z30013, Z30014, Z30018, Z30019, Z30012, Z3009, Z30430, Z30432, Z30433, Z3040, Z3041, Z304031, Z3049, Z3042, Z308, Z309, Z302 Pregnant females 82947, 82948, 82950, 82951, 82952, 83036 O0900, O0901, O0902, O0903, O0910, Females 87590, 87591, 87592, 87850 O0900, O0901, O0902, O0903, O0910, O0993, Z112, Z113, Z331, Z3400, Z3401, Z3402, Z3403, Z3480, Z3481, Revised 08/22/2016 4

Women Hepatitis B screening for pregnant women at their first prenatal visit HIV screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older 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 Sexually Transmitted Infections counseling for sexually active women Urinary tract or other infection screening for pregnant women Z3482, Z3483, Z3490, Z3491, Z3492, Z3493 Pregnant females 86706, 87340, 87341, 87515, 87516, 87517 O0900, O0901, O0902, O0903, O0910, Females 86689, 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, Females 30 and older with normal cytology results G0432, G0433, G0435 87620-87622, 87623-87625 Z0000, Z0001, Z01411, Z01419, Z0142, Z1151, Z124 Females 60 and over 76977, 77080, 77081, 77082, G0130 Z8262, Z0000, Z0001, Z13820 Females 86901 O0900, O0901, O0902, O0903, O0910, Females 99401-99404, G0445 Pregnant females 81007 O0900, O0901, O0902, O0903, O0910, 1 every 3 years Revised 08/22/2016 5

Women Well-woman visits to get recommended services for women under 65 Preventive Health Services for Children Autism screening for children at 18 and 24 months Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Cervical Dysplasia screening for sexually active females Depression screening for adolescents Developmental screening for children under age 17 Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 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 99381-99387, 99391-99397, G0402, G0438, G0439 Applies To CPT Codes ICD Codes Notes 1-2 Years 96110 Z0000, Z0001, Z00121, Z00129, Z13220 Age ranges Included with e/m 1/1/15 = new code added 96127 Females 88141-88175, 87620-87621, 87623, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, Q0091 G0444 99420 Z0000, Z0001, Z01411, Z01419, Z0142, Z1151, Z124 Z1389 0-17 years 96110 Z0000, Z0001, Z00121, Z00129, Z13220 0-18 years 80061, 82465, 83718, 83719, 83721, 84478 Z0000, Z0001, Z00121, Z00129, Z13220 Covered Under E/M or Obtained At Pharmacy Pharmacy benefit or provided in hospital at birth 0-90 DAYS V5008, 92551, 92558, 92585, 92586, 92587, 92588 1 per year Revised 08/22/2016 6

Children Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Hematocrit or Hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns HIV screening for adolescents at higher risk Applies To CPT Codes ICD Codes Notes Age ranges included with e/m 0-90 DAYS 85014, 85018 Z0000, Z0001, Z00121, Z00129, Z13220 0-90 DAYS S3850, 83020, 83021, 83030, 83033, 83051 86689, 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, G0432, G0433, G0435 0-90 DAYS 84437, 84443 **Hypothyroidism screening for newborns Immunization vaccines for 90460, 90461, 90471, 90472, 90473, 90474 children from birth to age 18 doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis 90696-90703, 90714, 90715, 90719-90723 Haemophilus influenzae type 90645-90648 B Hepatitis A 90632, 90633, 90634, 90636 Hepatitis B 90645, 90646, 90647, 90648 Human Papillomavirus 90649, 90650 Inactivated Poliovirus 90713 Influenza (Flu Shot) 90654-90664, 90685-90686 Measles, Mumps, Rubella 90704-90710 Meningococcal 90644, 90733, 90734 Pneumococcal 90669, 90670 Rotavirus 90680, 90681 Varicella 90716 Iron supplements for children ages 6 to 12 months at risk for anemia Pharmacy Benefit Revised 08/22/2016 7

Children Lead screening for children at risk of exposure Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Obesity screening and counseling Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. Phenylketonuria (PKU) screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Vision screening for all children. Applies To CPT Codes ICD Codes Notes 83655 Z0000, Z0001, Z00121, Z00129, Z1388, Z77011 included with e/m 97802-97804 Z0000, Z0001, Z00121, Z00129, Z1389 Pediatric Dental Program 0-1 years S3620, 84030 99401-99404, G0445 86580 R7611, R7612, Z00121, Z00129, Z111 99172, 99173 Z0000, Z0001, Z00121, Z00129, Z13220 Revised 08/22/2016 8