Preventive Services for Pregnancy SERVICE WHAT IS COVERED INTERVALS OF COVERAGE Anemia Screening Screening Annual screening for pregnant women

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Anemia Screening Screening Annual screening for pregnant women

Bacteriuria Screening Screening For pregnant women at 12-16 weeks gestation or first

prenatal visit

Breastfeeding Counseling Counseling During pregnancy and 1 year after birth

Gestational Diabetes Screening Screening For pregnant women after 24 weeks gestation

Hepatitis B Screening Screening For pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV) Screening Screening For pregnant women

Rh Incompatibility Screening Screening

For pregnant women during their first prenatal visit and repeated screening for unsensitized Rh(D)-negative women at 24-28 weeks gestation, unless the biological father is known to be Rh(D)-negative

Syphilis Screening Screening For pregnant women

Tobacco Use Screening & Counseling Screening & Counseling Screening for pregnant women and counseling for

pregnant women who smoke

Preventive Services for Pregnancy

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Gonorrhea Prophylactic Medication* Medication Birth

Hearing Loss Screening Screening Birth

Hematocrit/Hemoglobin Testing* Test One test between 4-11 months

Hemoglobinopathies/Sickle Cell Screening Screening Birth

Hypothyroidism Screening Screening Birth

Immunizations/Vaccinations See Child Immunization Schedule See Child Immunization Schedule

Lead Screening* Screening Only for newborns at risk of exposure

Pediatrician Preventive Visit

1. Blood Pressure 2. Developmental Screening

3. Height, Weight & Body Mass Index 4. Medical History 5. Office Visit

Birth, 3-5 days, 2 weeks, 1 month, 2 months, 4 months, 6 months and 9 months

Phenylketonuria (PKU) Screening Screening Birth

Oral Health Risk Assessment Assessment One assessment between 0-11 months

Preventive Services for Newborns (Age 0-11 Months)

Coinsurance Preventive Services

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Autism Screening Screening 18 months and 2 years

Dyslipidemia Test* Test 1, 2, 3, 4 and 5 years

Hematocrit/Hemoglobin Testing* Test One test between 1-5 years

Immunizations/Vaccinations See Child Immunization Schedule See Child Immunization Schedule

Lead Screening* Screening Only for children at risk of exposure

Pediatrician Preventive Visit

1. Blood Pressure 2. Developmental Screening

3. Height, Weight & Body Mass Index 4. Medical History 5. Office Visit

1 year, 15 months, 18 months, 2 years, 30 months, 3 years, 4 years and 5 years

Oral Health Risk Assessment Assessment One assessment between 1-5 years

Tuberculin Test* Test 1, 2, 3, 4 and 5 years

Visual Acuity Screening Screening One screening between 3-5 years

Preventive Services for Children (Age 1-5 Years)

Coinsurance Preventive Services

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Hematocrit/Hemoglobin Testing* Test One test between 6-10 years

Immunizations/Vaccinations See Child Immunization Schedule See Child Immunization Schedule

Lead Screening* Screening Only for children at risk of exposure

Pediatrician Preventive Visit

1. Blood Pressure 2. Developmental Screening 3. Dyslipidemia Test*

4. Height, Weight & Body Mass Index 5. Medical History

6. Obesity Screening & Counseling 7. Office Visit

8. Tobacco Use Intervention 9. Tuberculin Test*

6, 7, 8, 9 and 10 years

Oral Health Risk Assessment Assessment One assessment between 6-10 years

Skin Cancer Behavioral Counseling Counseling 10 years

Preventive Services for Children (Age 6-10 Years)

Coinsurance Preventive Services

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Cervical Dysplasia Screening Screening Only for sexually active young adolescents

Depression Screening Screening Annually for 12-14 years

Human Immunodeficiency Virus (HIV) Screening* Screening Only for young adolescents at risk

Immunizations/Vaccinations See Child Immunization Schedule See Child Immunization Schedule

Lead Screening* Screening Only for young adolescents at risk of exposure

Pediatrician Preventive Visit

1. Blood Pressure 2. Developmental Screening 3. Dyslipidemia Test*

4. Height, Weight & Body Mass Index 5. Hematocrit/Hemoglobin Test*

6. Medical History . 7. Obesity Screening & Counseling

8. Office Visit 9. Skin Cancer Behavioral Counseling

10. Tobacco Use Intervention 11. Tuberculin Test*

11, 12, 13 and 14 years

Sexually Transmitted Infections (STI) Counseling Counseling Only for sexually active young adolescents

Preventive Services for Young Adolescents (Age 11-14 Years)

Coinsurance Preventive Services

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Cervical Dysplasia Screening Screening Only for sexually active adolescents

Dyslipidemia Test* Test 15, 16, and 17 years

Hematocrit/Hemoglobin Testing* Test 15, 16, and 17 years

Human Immunodeficiency Virus (HIV) Screening* Screening Only for adolescents at risk

Immunizations/Vaccinations See Child Immunization Schedule See Child Immunization Schedule

Lead Screening* Screening Only for adolescents at risk of exposure

Pediatrician Preventive Visit

1. Blood Pressure 2. Depression Screening 3. Developmental Screening 4. Height, Weight & Body Mass Index 5. Medical History

6. Obesity Screening & Counseling 7. Office Visit 8. Skin Cancer Behavioral Counseling 9. Tobacco Use Intervention

15, 16, 17 & 18 years

Sexually Transmitted Infections (STI) Counseling Counseling Only for sexually active adolescents

Tuberculin Test* Test 15, 16, and 17 years

Preventive Services for Adolescents (Age 15-18 Years)

Coinsurance Preventive Services

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SERVICE WHAT IS COVERED INTERVALS OF COVERAGE

Alcohol Misuse Screening & Counseling* Screening & Counseling Only for adults engaged in risky or hazardous drinking

BRCA Risk Assessment, Genetic Counseling & Testing* Assessment, Counseling & Testing One-time screening only for women who have family members with breast, ovarian, tubal or peritoneal cancer

Cervical Cancer Screening Screening Every 3 years for women age 21 and older

Chlamydia Screening Screening For sexually active women age 24 or younger

Cholesterol Screening* Screening Only for men and women age 20 and older at risk for coronary heart

disease

Gonorrhea Screening Screening For sexually active women age 24 or younger

Healthy Diet & Physical Exercise Counseling* Counseling Only for overweight or obese adults that have additional

cardiovascular disease (CVD) risk factors

Hematocrit/Hemoglobin Testing* Test 19, 20 and 21 years

Hepatitis C Screening* Screening Only for adults at risk

Human Immunodeficiency Virus (HIV) Screening* Screening Only for adults at risk

Immunizations/Vaccinations See Adult Immunization Schedule See Adult Immunization Schedule

Intimate Partner Violence Screening & Counseling Screening & Counseling For women of childbearing age & counseling for women who test positive

Osteoporosis Screening* Screening Only for women under the age of 65 whose fracture risk is equal to or

greater than that of a 65 year old woman who has no additional risk factors

PCP OR OBGYN Physical Examinations

1. Blood Pressure 2. Depression Screening

3. Obesity Screening 4. Office Visit

5. Tobacco Use Screening 6. Skin Cancer Counseling

Annually

Sexually Transmitted Infections (STI) Counseling* Counseling Only for adults at high risk

Syphilis Screening* Screening Only for adults at high risk

Tobacco Use Counseling Counseling (Cessation Intervention) For adult tobacco users

Type 2 Diabetes Screening Screening Every 3 years for asymptomatic adults with sustained blood pressure

(treated or untreated) greater than 135/80 mm Hg

Breast Cancer Screening

(Preventive or Diagnostic) Screening at a WellStar Facility Unlimited

Colorectal Cancer Screening

PCP Visits Office Visit Unlimited

Preventive Services for Young Adults (Age 19-24 Years)

Coinsurance Preventive Services

(Additional preventive care once you have met your annual deductible)

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Breast Cancer Screening Screening For women 40-49 years

Breast Cancer Chemoprevention Medication For women who are at increased risk of breast cancer and low risk for adverse

medication effects

Cervical Cancer Screening Screening Every 3-5 years for women age 25 and older

Chlamydia Screening* Screening Only for sexually active women age 25 and older at high risk

Cholesterol Screening* Screening Only for men 25-34 years and women age 34 and older at risk for coronary heart

disease

Gonorrhea Screening* Screening Only for sexually active women age 25 and older at high risk

Healthy Diet & Physical Exercise Counseling* Counseling Only for overweight or obese adults that have additional cardiovascular disease

(CVD) risk factors

Hepatitis C Screening* Screening Only for adults at risk

Human Papillomavirus (HPV) DNA Test Test Every 3 years for women age 30 and older with normal cytology results

Obesity Counseling* Counseling Only for adults with a body mass index of 30kg/m2 or higher

Osteoporosis Screening* Screening Only for women age 29 and older whose fracture risk is equal to or greater than

that of a 65 year old woman who has no additional risk factors

1. Blood Pressure

2. Cholesterol Screening - For men age 35 and older 3. Depression Screening

4. Human Immunodeficiency Virus (HIV) Screening 5. Obesity Screening

6. Office Visit 7. Tobacco Use Screening

Annually

Type 2 Diabetes Screening Screening Every 3 years for asymptomatic adults with sustained blood pressure (treated or

untreated) greater than 135/80 mm Hg

Preventive Services for Adults (Age 25-49 Years)

Coinsurance Preventive Services (Additional preventive care once you have met your annual deductible)

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Breast Cancer Screening Screening For women age 50 and older

medication effects

Cervical Cancer Screening Screening Every 3-5 years for women age 50 and older

Cholesterol Screening* Screening Only for women age 50 and older at risk for coronary heart disease

Colorectal Cancer Screening Screening Every 5-10 years for adults age 50 and older

Healthy Diet & Physical Exercise Counseling* Counseling Only for overweight or obese adults that have additional cardiovascular disease (CVD)

risk factors

Hepatitis C Screening Screening One-time screening for adults born between 1945-1965 & for adults at risk

Lung Cancer Screening Screening Only for age 55 and older who have a 30 pack a year smoking history and currently

smoke or have quit within the past 15 years

Osteoporosis Screening* Screening Only for women age 50 and older whose fracture risk is equal to or greater than that of

a 65 year old woman who has no additional risk factors

1. Blood Pressure

2. Cholesterol Screening - For men age 50 and older 3. Depression Screening

Annually

Preventive Services for Adults (Age 50-64 Years)

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Abdominal Aortic Aneurysm Screening Screening For men 65-75 years with a history of smoking

Breast Cancer Screening Screening For women age 65 and older

medication effects

Cholesterol Screening* Screening Only for women age 65 and older at risk for coronary heart disease

Colorectal Cancer Screening Screening Every 5-10 years for adults 65-75 years

Fall Prevention Therapy* Exercise/Physical Therapy Only for community dwelling adults age 65 and older at risk for falls

Healthy Diet & Physical Exercise Counseling* Counseling Only for overweight or obese adults that have additional cardiovascular disease (CVD)

risk factors

Hepatitis C Screening Screening One-time screening for adults born between 1945-1965 & for adults at risk

Human Immunodeficiency Virus (HIV) Screening* Screening Only for adults age 65 and older that are at risk

Osteoporosis Screening Screening For women age 65 and older

PCP Physical Examinations

1. Blood Pressure

2. Cholesterol Screening - Only for men age 65 and older 3. Depression Screening

Annually