Preventive Guidelines

Preventive Health Care BenefitFrequencyAge LimitsICD 10 CodesCPT/HCPCSOther Requirement(s)
Abdominal Aortic Aneurysm Screening1 per lifetimeMen Ages 65-75Group 376706N/A
Abnormal Blood Glucose and Diabetes Screening and Counseling as part of cardiovascular risk assessment. Adults aged 40 to 70 who are overweight or obese; women with history of gestational diabetes mellitus1 per year Adults
1 per year Pregnant
Ages 40 to 70
Unless pregnant then no age limit
Group 1
Group 15
82947 or 83036N/A
Alcohol Substance Misuse 1 per yearNoneGroup 899408, 99409, G0396, G0397, G0442, G0443N/A
Anemia Screening1 per year PregnantNoneGroup 180055, 85013, 85014, 85018, 85025, 85027 or 80081N/A
Aspirin use for the prevention of preeclampsia for women over 12 weeks gestation and who are at high risk for preeclampsiaN/AN/ANot applicable, administered through PharmacyN/AOTC Aspirin (81 mg) is dispensed to member with a physician order at a participating pharmacy with no cost-sharing.
Bacteriuria Screening: using urine culture in pregnant persons.1 per year PregnantNoneGroup 1587081, 87084, 87086 or 87088N/A
BART Testing1 per lifetimeNoneAny Diagnosis81162, 81164, 81166, 81167 Prior Authorization Required.
Bilirubin Screening: infants with gestational age of 35 weeks or greater1 per lifetimeAges 0 - 8 DaysGroup 182247, 88720Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth.
BRCA Counseling1 per yearNoneGroup 1
Group 9
Group 10
96040, S0265No additional requirement.
BRCA Testing1 per lifetimeNoneAny Diagnosis81212, 81215, 81216, 81217, 81163, 81165 Prior Authorization Required.
Breast Cancer Chemoprevention1 per year for visit. No limit of fills on risk-reducing medications dispensed to member with a physician order with no cost-sharingFemale 35 years or olderGroup 999401-99402 or is included in wellness visit 99385-99387, 99395-99397This recommendation applies to asymptomatic women
aged 35 years or older without a prior diagnosis of breast
cancer, ductal carcinoma in situ, or lobular carcinoma in
situ. Risk-reducing medications are dispensed to member with a physician order with no cost-sharing.
Breast Cancer Screening: Mammograms and Digital Breast Tomosynthesis1 per yearFemale 40 years of age or older unless considered high risk then is 39 years of age or youngerGroup 1
Group 10
Group 9
77063, 77067N/A
Breast Cancer Screening: MRI1 per yearFemale 40 years of age or older unless considered high risk then is 39 years of age or youngerGroup 1
Group 10
Group 9
77048, 77049, C8903, C8905, C8906, C8908Prior Authorization Required.
Breastfeeding support, supplies, and counseling (Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for breastfeeding equipment)See Other RequirementsNoneGroup 599401, 99402, 99403, S9443, E0602, E0603, A4281, A4282, A4283, A4284, A4285, A4286Counseling covered at 100% through in-network providers (i.e., OB/GYNs, midwives, facilities); one breast pump provided per pregnancy through in-network DME providers. Replacement supplies for breast pumps or initial supplies for member owned breast pump will be provided with no cost sharing to appropriate groups Replacement supplies cannot be provided with the initial breast pump as they are included in the initial purchase of the pump 99401-99403 are to be used in the absence of a wellness visit.
Cervical cancer/HPV screeningWomen 21-29 years of age every 3 years by cytology and age 30-65 years of age every 3 years with cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting)Women 21-29 years of age every 3 years by cytology and age 30-65 years of age every 3 years with cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting)Group 188141-88155, 88164-88167, 88174-88175, G0101, Q0091, S0601-S0613, 87624, 87625N/A
Chlamydial Infection Screening 1 per year and 1 per year pregnantWomen 24 and Older unless pregnant in which case there is no age limitGroup 2
Group 15
87270, 87320, 87490, 87491 and 87810N/A
Cholesterol Abnormalties/Lipid Disorder Screening 1 per yearSee other requirementsGroup 180061, 82465 or 83718Men 35 and older (for lipid disorders) *men younger than 35 (for ages 20-35 for lipid disorders if they are at increased risk for coronary heart disease)Women 20 and older (for lipid disorders if they are at increased risk for coronary heart disease) See also: Statin Use for the Primary Prevention of Cardiovascular Disease in
Adults.
Colorectal Cancer Screening - Colonoscopy1 per 10 years unless high risk in which case is 1 per 2 yearsAges 50 - 75 unless high risk in which case is ages 18-75Group 13
Group 14
45378, 45380, 45381, 45382, 45384, 45385, 45388, S0285, G0105, G0121N/A
Colorectal Cancer Screening - CT Colonography1 per 5 yearsAges 50-75 unless high risk in which case is ages 18-75Group 13
Group 14
74263Prior Authorization Required.
Colorectal Cancer Screening - Sigmoidoscopy1 per 5 years unless high risk in which case is 1 per 2 yearsAges 50 - 75 unless high risk in which case is ages 18-75Group 13
Group 14
45330, 45331, 45333, 45334, 45335, 45338, 45346, G0104N/A
Contraceptive methods and counseling

N/AN/AN/APart of preventive
visit (99384, 99385, 99386, 99394, 99395, 99396), 99401, 99402, A4264, J1050, J7296, J7298, J7300, J7301, J7306, J7307, 11981,11982, 11983, 57170, 58300, 58565, 58600, 58605, 58611, 58615, 58671, 58670, 96372, 11976, 58301, 00851
For contraceptive medications and devices covered at 100% under the pharmacy benefit see Formulary Lookup Tool. Also,
99401-99402 may be used for counseling in the absence of a wellness visit.
Depression Screening

Adults (screening for depression, including pregnant and postpartum women, when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up)

Adolescents (screening 12-18 yr olds for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy [cognitive-behavioral or interpersonal], and follow-up)
1 per yearAges 12 years and aboveGroup 1
Group 2
G0444N/A
Developmental Screening1 annuallyUp to age 18Group 1
Group 2
96110N/A
Emotional/behavioral assessment1 per yearNoneGroup 1
Group 2
96127N/A
Fall Prevention

(Exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.)
3 annual - any combination Ages 65 and OlderGroup 497110, 97112, 97116, 97530, G0151, G0157, G0159, S9131 and S9476.N/A
Fecal DNA (Cologuard)1 per 3 yearsAges 50 - 75Group 1381528N/A
FIT1 per yearAges 50-75 unless high risk in which case is ages 18-75Group 13
Group 14
82274N/A
Flouride Varnish1 quarterlyUp to age 5Group 199188N/A
FOBT1 per yearAges 50-75 unless high risk in which case is ages 18-75Group 13
Group 14
82270N/A
Folic Acid supplementation for all women planning or capable of pregnancy

All women planning or capable of pregnancy to take a daily supplement containing 0.4 - 0.8 mg [400-600 mcg] of folic acid
N/AN/ANot applicable, administered through PharmacyN/AOTC folic acid supplements are dispensed to member with a physician order with no cost-sharing.
Gestational Diabetes Mellitus (GDM) Screening in asymptomatic pregnant women after 24 weeks of gestation.1 per pregnancyNoneGroup 1582950N/A
Gonorrhea Screening

Women who are sexually active that are at increased risk for infection [if they are young or have other individual or population risk factors])

Pregnant Women
1 per year
1 per year Pregnant
NoneGroup 2
Group 15
87590-87591 and 87850N/A
Group B strep testing performed one time during pregnancy1 per pregnancyNoneGroup 1587081N/A
Hemoglobinopathies Screening
(for sickle cell disease in newborns)
1 per lifetimeAges 0 - 8 DaysZ00.11083020, 83021, 85660 and S3620Service is typically performed in the birth facility or as part of a wellness office visit.
Hepatitis B Screening
(in pregnant women at first prenatal visit and in persons at high risk for infection.)
1 per year Persons at high risk for infection
and 1 per year Pregnant
Ages 13-79 unless pregnant then at any ageGroup 2
Group 15
80055 , 87340 or 80081N/A
Hepatitis C Virus (HCV) Screening
(for persons at high risk for infection.) The USPSTF also recommends offering one-time screening for HCV infection to adults aged 18 to 79.
1 every 10 yearsAges 18 - 79Group 2G0472N/A
High Blood Pressure Screening
(Recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment)
Ages 18 and OlderGroup 1 may be used with 99385-99387 or 99395-99397.
For coverage of 93784, 93786, 93788, 93790, A4670 must bill with R03.0.
99385-99387 or 99395-99397

For ambulatory blood pressure monitoring use 93784, 93786, 93788, 93790

For home blood pressure monitor use A4670
99385-99387 or 99395-99397 are part of the wellness visit
HIV Infection Prevention with Preexposure prophylaxis
(Persons at high risk of acquiring HIV. Offer
preexposure prophylaxis (PrEP) with
effective antiretroviral therapy to persons
who are at high risk of HIV acquisition,
including monitoring required prior to
initiation of therapy and during drug
therapy).
Z11.4Prior to initiation of therapy: 87806, 82575, 80069, G0472, 87340, 81003, 77080 or 77081, 81025

Monitoring every 3 months: 87806, 80055, 86592, 86780 or 80081; 87270, 87320, 87490, 87491 or 87810, 87590,
87591 or 87850 , 81025

Monitoring every 6
months: 82565
For medications covered at 100% please use the Formulary Lookup Tool on AlliantPlans.com
HIV Screening 1 per year Persons at high risk
and 1 per year Pregnant
Ages 15 - 65 unless pregnant then at any ageGroup 2
Group 15
G0432, G0433, G0435, OR G0475N/A
Iron supplementation in children (routine iron supplementation for asymptomatic children 6-12 mo of age who are at increased risk for iron deficiency anemia)N/AN/ANot applicable, administered through PharmacyN/AN/A
Lead Screening 1 per yearAges 7 and UnderGroup 1
83655N/A
Lung Cancer Screen (LDCT)1 per yearAges 55 - 80Group 371271Prior Authorization Required.
Lung Cancer Screen (LDCT) Counseling1 per yearAges 55 - 80Group 3G0296N/A
Nutritional Counseling

Healthful diet and physical activity for
cardiovascular disease prevention in
adults with cardiovascular risk factors.

(Recommends offering or referring adults
who are overweight or obese and have
additional cardiovascular disease (CVD) risk
factors to intensive behavioral counseling
interventions to promote a healthful diet and
physical activity for CVD prevention.)
1 - Preventive
4 - Medically Necessary
Ages 6 and OverGroup 6
Group 7
97802, 97803, 97804, 99401, 99402, 99403, 99404, S9470, G0447, G0473N/A
Osteoporosis Screening - Bone density CT1 every two yearsAge 65 and Older unless high risk in which case is age 20 and olderGroup 11
Group 12
77078Prior Authorization
Osteoporosis Screening - Bone density tests1 every two yearsAge 65 and Older unless high risk in which case is age 20 and olderGroup 11
Group 12
76977, 77080, 77081, 77085N/A
PKU Screening (in newborns)1 per lifetimeAges 0 - 8 DaysGroup 184030N/A
Prophylactic medication for gonorrhea: newborns (ocular topical medication for all newborns against gonococcal ophthalmia neonatorum)N/AN/ANot applicable, administered through FacilityN/AThis medication is generally administered to newborn at birth facility.
Prostate Screening 1 AnnuallyMales Ages 50 - 70Group 1
Group 10
G0102, G0103N/A
Sensory Screening - Hearing
(beyond newborn screening)
Covered annuallyAges infant through 18 yearsGroup 199382, 99383, 99384, 99385, 99392, 99393, 99394, 99395, 92551, 92558 or 92586May be part of wellness visits.
Sexually Transmitted Infections Counseling
(recommends high-intensity behavioral counseling to prevent STIs for all active adolescents and for adults at increased risk for STIs)
1 AnnuallyNoneGroup 2G0445N/A
Syphilis Screening1 per year Persons at increased risk
and 1 per year Pregnant
NoneGroup 2
Group 15
80055, 86592, 86780 or 80081N/A
Tobacco Cessation 1 AnnuallyNoneGroup 1
Group 3
99406, 99407N/A
Tuberculosis Screening for persons at higher risk
1 annuallyAll agesGroup 186580N/A
Vaccines Recommended by the Centers for Disease Control

Diphtheria, Tetanus, Pertussis
Measles, Mumps, Rubella
Haemophilus Infuenzae Type B
Hepatitis A
Hepatitis B
Influenza
Pneumococcal
Meningococcal
Human Papillomavirus (HPV)
Inactivated Poliovirus
Rotavirus
Varicella
Tetanus-Diphtheria /Tetanus-Diphtheria Acellular Pertussis
Herpes Zoster (Shingles)
Adult and Child & Adolescent Immunization Schedules (for
persons aged 0-6 years, 7-18 years, and “catch-up schedule”)
Refer to the CDC’s posted schedule of immunizations
http://www.cdc.gov/vaccines/schedules/index.html
N/AN/AGroup 1N/ADoses, recommended ages and recommended populations vary. All recommended routine immunizations will be allowed with no cost share.
Visual Acuity Screening1 annuallyUp to Age 18Group 199173, 99174, 99177N/A
Wellness Exams
Include the following service when applicable:
- Developmental Surveillance
- History and assessment of the physical state (height, weight, BP (blood pressure), BMI (body mass index))
- Screening for congenital hypothyroidism (In newborns)
- Screening and counseling for interpersonal and domestic violence The USPSTF recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer
women who screen positive to ongoing support services
- UV light exposure counseling for persons age 6 months to 24 years
Follows Pediatric Guidelines
for ages 3 and under for ages 4 and older is 1 annually and for age 11 and older is 1 annually with availability to see OBGYN for preventive care.

See Frequency Covered at Preventive Benefit for
details
Group 1G0402 - G0405, G0438 - G0439, 99401 - 99404, 99411, 99412, 99429, 99381 - 99387, 99391 - 99397, S0302N/A