Preventive Guidelines

NOTICE: The preventive guidelines displayed below are intended as a billing resource for providers. Benefits and services are subject to change by Alliant. To understand if you or your patient qualifies for these benefits, refer to the Member’s Certificate of Coverage or call Client Services at (800) 811-4793.

As new recommendations and guidelines for preventive care are published by the government sources identified above, they will become covered under the member’s Contract for plan years which begin one year after the date the recommendation or guideline is issued or on such other date as required by the Affordable Care Act. The plan year, also known as a policy year for the purposes of this provision, is based on the calendar year.

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 limitGroup 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, 99386, 99387, 99395, 99396, 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: 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, 77049Prior Authorization Required.
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
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, 99404, S9443, E0602, E0603, A4281, A4282, A4283, A4284, A4285, A4286, *E0604, K1005Counseling covered at 100% through in-network providers (i.e., OB/GYNs, midwives, facilities); one breast pump provided per pregnancy through in-network DME providers. 99401-99403, 99404** are to be used in the absence of a wellness visit. *E0604 is covered as rental only.
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 1
Group 10		88141, 88142, 88143, 88144, 88145, 88146, 88147, 88148, 88149, 88150, 88151, 88152, 88153, 88154, 88155, 88164, 88165, 88166, 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		 87110, 87270, 87320, 87490, 87491, 87801, 87810, 86631, 86632, 87492, 36415, 36416N/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#colspan##colspan##colspan##colspan##colspan#
Colorectal Cancer Screening - Colonoscopy1 per 10 years unless high risk in which case is 1 per 2 yearsAges 45-75 - Routine
Ages 18-75 - High Risk		Group 13
Group 14		45378, 45380, 45381, 45382, 45384, 45385, 45388, S0285, G0105, G0121N/A
Colorectal Cancer Screening - CT Colonography1 per 5 yearsAges 45-75 - Routine
Ages 18-75 - High Risk		Group 13
Group 14		74263Prior Authorization Required.
Colorectal Cancer Screening - FIT1 per yearAges 45-75 - Routine
Ages 18-75 - High Risk		Group 13
Group 14		82274N/A
Colorectal Cancer Screening - Sigmoidoscopy1 per 5 years unless high risk in which case is 1 per 2 yearsAges 45-75 - Routine
Ages 18-75 - High Risk		Group 13
Group 14		45330, 45331, 45333, 45334, 45335, 45338, 45346, G0104N/A
Colorectal Cancer Screening - Fecal DNA (Cologuard)1 per 3 yearsAges 45 - 75 - RoutineGroup 1381528N/A
Colorectal Cancer Screening - FOBT1 per yearAges 45-75 Routine
Ages 18-75 High Risk		Group 13
Group 14		82270N/A
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Contraceptive methods and counseling N/AN/AGroup 1Part 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
Flouride Varnish1 quarterlyUp to age 5Group 199188N/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 acidN/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 Women1 per year
1 per year Pregnant		NoneGroup 2
Group 15		87590, 87591, 87801 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 PregnantAges 13-79 unless pregnant then at any ageGroup 2
Group 15		87340, 80055 , 80081, 36415, 36416N/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 286803, G0472, 36415, 36416N/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, 99386, 99387 or 99395, 99396, 99397 For ambulatory blood pressure monitoring use 93784, 93786, 93788, 93790 For home blood pressure monitor use A467099385-99387 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). HIV PrEP CodesFor 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 PregnantAges 15 - 65 unless pregnant then at any ageGroup 2
Group 15		G0432, G0433, G0435, G0475, S3645, 36415, 36416, 86701, 86703, 87389, 86702N/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 50 - 80Group 371271Prior Authorization Required.
Lung Cancer Screen (LDCT) Counseling1 per yearAges 50 - 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 NecessaryAges 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
Rh(D) blood typing and antibody testing for all pregnant women 2 per pregnancy - The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative. #colspan#Group 1586901, 86850, 36415, 36416
Sensory Screening - Hearing (beyond newborn screening)Covered annuallyAges infant through 18 yearsGroup 199382, 99383, 99384, 99385, 99392, 99393, 99394, 99395, 92551, 92558, 92586, 92650, 92651May 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 PregnantNoneGroup 2
Group 15		36415, 36416, 80055, 80081, 86592, 86593, 86780N/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 Influenzas 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 CDCs posted schedule of immunizations http://www.cdc.gov/vaccines/schedules/index.htmlN/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 yearsFollows 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 detailsGroup 1G0438, G0439, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, S0302, 80050, 81002, 81003, 84437, 84443, 82951, 82952, 86704, 86705, 86706, 86900, 87522, 99000, 80053, 36415, 36416N/A