Essential Preventive Health Services for Adults and ...



Women’s Preventive Services – Effective August 1, 2012 for new plans and upon renewal

Non-grandfathered plans, grandfathered plans with the 09/23/2010 prevent services, and issuers are required to provide coverage without cost sharing consistent with these guidelines in the first plan year that begins on or after August 1, 2012. The services listed below are covered in full when received from a provider within the plan’s network. This list is not all-inclusive; however, it is to be used as a guideline for allowing benefits. Any code NOT on this list must be reviewed by the Medical Director before allowing at the HCR 100% benefit. Services may vary by plan/state. When a service does not mention a frequency, there is no limit; however, it is subject to medical necessity.

Note: Coverage of Well Woman Preventive Care, must be extended to dependent children to include a full range of recommended preventive services applicable to them (e.g. age appropriate and developmentally appropriate). M = Men only, W = Women only

|Mandated Services |Services Schedule |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|Breastfeeding Support, Supplies and |Comprehensive lactation support and counseling, by |09/01/2009 |ICD9 – V24.1, 676.8 |98960 |Affinity Markets and Group = OME* |

|Counseling W |a trained provider during pregnancy and/or in the |11/01/2017 |ICD10 – O92.79, Z39.1 | |Starmark = PLA |

|Breastfeeding Services and Supplies W |postpartum period, and costs for purchasing and | | | |*CPT will except out. Requires processor review|

| |renting breastfeeding equipment. | | | |to pay HCR 100% in-network benefit. |

| |Comprehensive lactation support services (including| | | | |

| |counseling, education and breastfeeding equipment | | | | |

| |and supplies) during the antenatal, perinatal and | | | | |

| |the postpartum period to ensure the successful | | | | |

| |initiation and maintenance of breastfeeding. | | | | |

| |OON claims for lactation counselors are to be paid | | | | |

| |at 100% | | | | |

| |Frequency is in conjunction with each birth. | | | | |

| |Refer to the Breast Pump memorandum in the Breast | | | | |

| |Pump BRS entry for additional information. | | | | |

| | | | |99241, 99242, 99243, 99244, |Affinity Markets and Group = RPE |

| | | | |99245, 99341, 99342, 99343, |Starmark = POV (for all service types) |

| | | | |99344, 99345, 99346, 99347, | |

| | | | |99348, 99349, 99350, 99401, | |

| | | | |99402, 99403, 99404 | |

| | | | |A4281, A4282, A4283, A4284, | |

| | | | |A4285, A4286, | |

| | | | |E0602, E0603, E0604, | |

| | | | |S9443 | |

|Breast Cancer (Mammography) W |Every one or two years for ages 40 and older |09/01/2005 |ICD9 – V76.1 |77052, 77055, 77056, 77057 |Affinity Markets and Group = SPX |

|Breast Cancer Screening for Average- Risk |Administrative guideline to allow 3D mammograms |07/01/2017 |ICD10 – Z12.31, Z12.39 |G0202, G0204, G0206 |Starmark = PXR |

|Women W |Mammography screening no earlier than age 40 and no|11/01/2017 | | | |

| |later than age 50 for average-risk women. | | |Effective 07/01/2017: | |

| |Screening mammography should occur one to two times| | |77061, 77062, 77063, G0279 | |

| |annually. Screening should continue through at | | | | |

| |least age 74 (but not discontinue based on age | | | | |

| |alone). | | | | |

| |Women at increased risk should also undergo | | | | |

| |periodic mammography screening. However, | | | | |

| |recommendations for additional services are beyond | | | | |

| |the scope of this recommendation. | | | | |

|Cervical Cancer (PAP Smear and HPV |Once every year for women age 21 and older |03/01/2013 |ICD9 – V72.3, V76.2 |88141, 88142, 88143, 88144, |Affinity Markets and Group = SPL |

|Testing) W |Cervical cancer screening for average-risk women |11/01/2017 |ICD10 – Z01.411, Z01.419, |88145, 88146, 88147, 88148, |Starmark = PLA |

|a.k.a. Screening for Cervical Cancer |ages 21-65. | |Z12.4 |88149, 88150, 88151, 88152, | |

| |Ages 21-29, cervical cancer screening using Pap | | |88153, 88154, 88155, 88164, | |

| |test every 3 years. | | |88165, 88166, 88174, 88175, | |

| |(co-testing with Pap and HPV is not recommended for| | |Q0091 | |

| |women under 30 years) | | | | |

| |Ages 30-65, Pap test and HPV testing every 5 years | | | | |

| |or Pap test alone every 3 years. | | | | |

| |Women who are at average risk should not be | | | | |

| |screened more than once every 3 years. | | | | |

| | | | |88167 |Affinity Markets and Group = RLB |

| | | | | |Starmark = PLA |

|Contraceptive Methods (FDA-Approved) as |Women will have access to all FDA-approved |08/01/2012 |ICD9 – V25.01-V25.04, |00952, 00851, |Affinity Markets and Group |

|Prescribed & Contraceptive Counseling W |contraceptive methods, sterilization procedures |1a. 11/01/2017 |V25.09, V25.11, V25.13, |11976, 11980, 11981, 11982, |= RSR, RAN, RPE, IMM, RXY, RPR, RPE |

|1a. Contraception W |(including pre-operative services) and patient |01/01/2014 |V25.2, |11983, |Note: Contraceptives will automatically switch |

| |education and counseling. (This includes | |V25.41-V25.43, V25.49, |57170, 58300, 58301, 58340, |to RPE when using one of the S- HCPCS codes |

| |“Emergency Contraceptives”, “Abortifacient” drugs, | |V25.5, V25.8, V25.9, |58565, 58600, 58605, 58611, | |

| |and insertion and removal of IUDs.) | |V26.51 |58615, 58670, 58671, 58700, |Starmark |

| |Frequency is as prescribed. | |ICD10 – Z30.02, Z30.09, |74740, 96372, |= PHO when received on a UB04 |

| |1a. Adolescent and adult women will have access to | |Z30.011, Z30.012, Z30.014,|A4261, A4264, A4266, A4268, |= PXR when received on a HCFA |

| |all FDA-approved contraceptive methods, effective | |Z30.018, Z30.2, Z30.40, |A4269, |= POV for contraceptives when using one of |

| |family-planning practices and sterilization | |Z30.41, Z30.430, Z30.431, |J1050, J1051, J1056, J1885, |the Sxxxx and J7xxx HCPCS codes |

| |procedures available as part of contraceptive care | |Z30.433, Z30.49, Z30.8, |J3490, J7297, J7298, J7300, | |

| |to prevent unintended pregnancy and improve birth | |Z30.9, Z98.51 |J7302, J7303, J7304, J7306, | |

| |outcomes. Contraceptive care initiation of | | |J7307, | |

| |contraceptive use and follow-up care (e.g., | | |Q9984, S4981, S4989, | |

| |management and evaluation, as well as changes to | | | | |

| |and removal/discontinuation of contraceptive | | | | |

| |method). | | | | |

| |OTC contraception is covered if FDA approved and | | | | |

| |prescribed for a woman by her provider. | | | | |

| |Note: this does not include male condoms | | | | |

| |Refer to the list on the right for a full range of | | | | |

| |FDA identified contraceptive methods for women and | | | | |

| |details on patient liability. This list can also | | | | |

| |be located in the Contraceptive entry in the Claim | | | | |

| |Administration section of the BRS. | | | | |

| |Note: The above does not apply to women who are | | | | |

| |participants or beneficiaries in group health plans| | | | |

| |sponsored by religious employers. | | | | |

| | | | |S4993 |Affinity Markets and Group = RPE |

| | | | |also any office visit code with |Starmark = POV |

| | | | |these diagnosis codes | |

| | |FDA Identified Contraceptive Methods: |

| | |The full range of contraceptive methods for women currently identified by the FDA include: |

| | |Cervical Caps |

| | |Female Condoms |

| | |Diaphragms |

| | |Emergency Contraception (Levonorgestrel and Ulipristal Acetate) |

| | |Copper Intrauterine Devices |

| | |Intrauterine Devices With Progestin (All Durations and Doses) |

| | |Oral Contraceptives (“Combined” Pills) |

| | |Oral Contraceptives (Progestin Only) |

| | |Oral Contraceptives (Extended or Continuous Use) |

| | |The Contraceptive Patch |

| | |Vaginal Contraceptive Rings |

| | |Implantable Rods |

| | |Contraceptive Sponges |

| | |Shot or Injection |

| | |Spermicides |

| | |Sterilization Surgery for Women |

| | |Surgical Sterilization Via Implant for Women |

| | |Additional methods as identified by the FDA |

| | | |

| | |Additionally, instruction in fertility awareness-based methods, including the lactation amenorrhea method, although less |

| | |effective, should be provided for women desiring an alternative method. |

| | |Note: The above do not apply to women who are participants or beneficiaries in group health plans sponsored by religious |

| | |employers. |

|Domestic Violence and Counseling W |Screening and counseling for interpersonal and |01/01/2014 |ICD9 – V15.41, V15.42, |96150, 98960, |Affinity Markets and Group = RPE |

|Screening and Counseling for Interpersonal|domestic violence |11/01/2017 |V15.49, V61.11, V61.12, |99401, 99402, 99403, 99404, 99420|Starmark = POV |

|and Domestic Violence W |Screening of adolescents and women for | |V61.21, V62.81, | | |

| |interpersonal and domestic violence at least | |995.81-995.83 | | |

| |annually and, when needed, providing or referring | |ICD10 – T74.11XA, | | |

| |for initial intervention services | |T74.21XA, T74.31XA, | | |

| | | |T76.11XA, T76.21XA, | | |

| | | |T76.31XA | | |

| | | |Z65.8, Z69.010, Z69.11, | | |

| | | |Z69.12, Z91.410, Z91.411, | | |

| | | |Z91.412, Z91.49 | | |

|Screening for Gestational Diabetes |Screening for women after 24 weeks pregnant, and |01/01/2015 |ICD9 – V77.1 |82947, 82948, 82950, 82951, |Affinity Markets and Group = RLB / RPP |

|Mellitus W |those at high risk of developing gestational |11/01/2017 |ICD10 – Z13.1 |82952, 83036 |Starmark = PLA / PPL |

| |diabetes | | | | |

| |Screening for women after 24 weeks of gestation | | | | |

| |(preferably between 24 and 28 weeks of gestation) | | | | |

| |or for those at high risk of developing gestational| | | | |

| |diabetes, screening before 24 weeks of gestation – | | | | |

| |ideally at the first prenatal visit, based on | | | | |

| |current clinical best practices | | | | |

|Human Immunodeficiency Virus (HIV) |Annual screening and counseling on HIV infections |01/01/2012 |ICD9 – V08 | | |

|Screening and Counseling W |Annual screening throughout the lifespan on |11/01/2017 |ICD10 – Z21 | | |

|Screening for Human Immunodeficiency Virus|HIV-prevention education and risk assessment in | | | | |

|(HIV) Infection W |adolescents and women. Additional screening | | | | |

| |annually or more often may be appropriate for | | | | |

| |adolescents and women with an increased risk of HIV| | | | |

| |infection | | | | |

| |Screening for HIV is recommended for all pregnant | | | | |

| |women upon initiation of prenatal care with | | | | |

| |retesting during pregnancy based on risk factors. | | | | |

|Human Papilloma Virus (HPV) DNA Testing |Women who are 21 or older will have access to |01/01/2012 |ICD9 – V70.0, V72.31, |87620, 87621, 87622, 87623, |Affinity Markets and Group = RLB / RPP |

|for Women Age 30 and Older W |screening every three years |11/01/2017 |V73.81, V76.2 |87624, 87625 |Starmark = PLA / PPL |

| |Refer to Cervical Cancer in this document | |ICD10 – Z00.00, Z01.411, | | |

| | | |Z01.419, Z11.51, Z12.4 | | |

|Preeclampsia Prevention W |Low-dose aspirin (81 mg/d) as preventive medication|09/01/2014 | | | |

| |after 12 weeks of gestation in women who are at |04/01/2018 | | | |

| |high risk for preeclampsia | | | | |

| |Preeclampsia screening for preeclampsia in pregnant| | | | |

| |women with blood pressure measurements throughout | | | | |

| |pregnancy | | | | |

|Prenatal Care W |Routine prenatal obstetrical office visits must be | | | |See Screening for Pregnant Women section |

| |covered at 100% whether group has a maternity | | | | |

| |coverage option or not | | | | |

| |(see also Well Woman Visits in this document) | | | | |

|Counseling for Sexually Transmitted |Counseling on STI’s for those who are at increased |01/01/2012 |V65.44, V65.45 |G0445 |Affinity Markets and Group = RPE |

|Infections (STI) W |risk for sexually transmitted infections |11/01/2017 | | |Starmark = POV |

| |Behavioral counseling for sexually active | | | | |

| |adolescents and adult women at an increased risk | | | | |

| |for sexually transmitted infections STIs. | | | | |

| |For adolescents and women not identified as high | | | | |

| |risk, counseling to reduce the risk of STIs should | | | | |

| |be considered, as determined by clinical judgement.| | | | |

Essential Preventive Health Services for Adults

The following information pertains to any plans effective September 23, 2010 or later, as well as non-grandfathered plans, and grandfathered plans with this election. The routine exams, immunizations and screenings for adults age 18 and older listed below are covered in full when received from a provider within the plan’s network. This list is not all-inclusive; however, it is to be used as a guideline for allowing benefits. Any code NOT on this list must be reviewed by the Medical Director before allowing at the HCR 100% benefit. Services may vary by plan/state. When a service does not mention a frequency, there is no limit; however, it is subject to medical necessity. M = Men only, W = Women only

|Wellness Exams / Health Screenings For |Services Schedule |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|Abdominal Aortic Aneurysm M |Ultrasound screening for all men ages 65-75, one |02/01/2006 |ICD9 – V81.2 |76770, 76705, 76775 |Affinity Markets and Group = RLB |

| |time in lifetime |01/01/2015 |ICD10 – Z13.6 | |Starmark = PRA |

| |For men ages 65 to 75 years of age who have ever | | | | |

| |smoked | | | | |

|Alcohol Misuse Screening and Counseling |Counseling sessions for patients age 18 or older |05/01/2014 |ICD9 – 305.0, V79.1 |90804 |Affinity Markets, Group and Starmark = PFP |

| |who meet criteria for alcohol misuse | |ICD10 – F10.10, F10.120, | |CPT will except out. Requires processor review to |

| | | |F10.129, Z13.89 | |pay HCR 100% in-network benefit. |

| | | | |96150, |Affinity Markets and Group = PTE* |

| | | | |G0442, G0444 |Starmark = POV |

| | | | | |*CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

| | | | |98960 |Affinity Markets and Group = OME* |

| | | | | |Starmark = PLA |

| | | | | |*CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

| | | | |99384, 99385, 99386, 99387, |Affinity Markets & Group = RPE |

| | | | |99394, 99395, 99396, 99397, |Starmark = POV |

| | | | |99401, 99402, 99420 | |

| | | | |H0001 |Affinity Markets, Group and Starmark = PFP |

| | | | | |CPT will except out. Requires processor review to |

| | | | | |pay HCR 100% in-network benefit. |

| | | | |H0049 |Affinity Markets and Group = PHT |

| | | | | |Starmark = OCT |

| | | | | |CPT will except out. Requires processor review to |

| | | | | |pay HCR 100% in-network benefit. |

|Breast Cancer – High Risk (Cancer |Women beginning at age 40 at high risk for breast |09/23/2010 | |99401, 99402, 99403, 99404 |Affinity Markets and Group = RPE |

|Prevention Counseling) W |cancer | | | |Starmark = POV |

|Breast Cancer Preventive Medication W |Risk-reducing medications, such as Tamoxifen and |09/01/2014 | | | |

| |Raloxifene,for women with increased risk for | | | | |

| |breast cancer | | | | |

|Cardiovascular Disease (CVD) |General Counseling and Counseling on the use of |03/01/2009 | |99401, 99402, 99403, 99404 |Affinity Markets & Group = RPE |

| |aspirin |01/01/2014 | | |Starmark = POV |

| |Over the counter aspirin is covered for men age 45|11/01/2017 | | | |

| |to 79 and women age 55 to 79 at risk of | | | | |

| |cardiovascular disease when prescribed by a doctor| | | | |

| |Statin preventive medication for adults ages 40-75| | | | |

| |years with no history or CVD, 1 or more CVD risk | | | | |

| |factors and a calculated 10-year CVD event risk of| | | | |

| |10% or greater | | | | |

| | | | |OTC Aspirin |Starmark = NPD |

|Chlamydia Infection W |For all sexually active non-pregnant women up to |06/01/2005 |ICD9 – V73.88, V73.98 |87110, 87270, 87320, |Affinity Markets and Group = RLB |

| |age 24 and older non-pregnant women who are at | |ICD10 – Z11.8 |87490, 87491, 87492, 87810 |Starmark = PLA |

| |increased risk | | | | |

|Cholesterol Screening |For men ages 20 to 35 at increased risk of |06/01/2009 |ICD9 – V77.91 |82465, 83718, 83719 |Affinity Markets and Group = RLB |

| |cardiovascular disease and women age 20 to 45 who | |ICD10 – Z13.220 | |Starmark = PLA |

| |are at increased risk of cardiovascular disease; | | | | |

| |otherwise, beginning at age 35 for men and age 45 | | | | |

| |for women. | | | | |

|Colorectal Cancer Screening |Follow American Cancer Society guidelines posted |10/01/2009 |ICD9 – V76.51 |45330, 45331, 45332, 45333, |Affinity Markets and Group= RSR |

| |in the BRS: | |ICD10 – Z12.11 |45334, 45335, 45336, 45337, |Starmark = PXR |

| |Beginning at age 50, w/o specific risk factors: | | |45338, 44339, 44340, 44341, | |

| |Every year – fecal occult blood test or fecal | | |44342, 44343, 44344, 45345, | |

| |immunochemical test | | |45355, 45356, 45357, 45358, | |

| |Every 5 years – flexible sigmoidoscopy, | | |45359, 45360, 45361, 45362, | |

| |double-contract barium enema or CT colonography | | |45363, 45364, 45365, 45366, | |

| |Every 10 years – Colonoscopy | | |45367, 45368, 45369, 45370, | |

| |(includes pre-procedure consultation, bowel | | |45371, 45372, 45373, 45374, | |

| |preparation kit and pathology exam, anesthesia | | |45375, 45376, 45377, 45378, | |

| |services performed in connection with the | | |45379, 45380, 45381, 45382, | |

| |colonoscopy and biopsy/pathology related to | | |45383, 45384, 45385, 45386, | |

| |incidental polyp removal regardless if routine or | | |45387, 45388, 45389, 45390, | |

| |not) | | |45391, 45392, 74261, 74262, | |

| |Screening should begin earlier and more frequently| | |74263, 82270, | |

| |for patients with colorectal cancer risk factors. | | |G0328, G0104, G0105, G0106, | |

| |See BRS for risk factors. | | |G0107, G0120, G0121, G0122 | |

| | | | |82274, |Affinity Markets and Group= RLB |

| | | | |88305, 88305-26 |Starmark = PLA |

|Depression Screening |As medically necessary |12/01/2010 |ICD9 – V79.0 |99420 |Affinity Markets and Group = RPE |

| | | |ICD10 – Z13.89 | |Starmark = POV |

|Diabetes (type 2) Screening |For individuals with high blood pressure greater |06/01/2009 |ICD9 – V77.1 |82947, 82948, 82949, 82950, |Affinity Markets and Group = RLB |

| |than 135/80 | |ICD10 – Z13.1 |82951, 82952, 82962, 83037 |Starmark = PLA |

| | | | |99385, 99386, 99395, 99396 |Affinity Markets and Group = RPE |

| | | | | |Starmark = POV |

|Falls Prevention |Exercise or physical therapy and Vitamin D |05/01/2013 |ICD9 – V15.8, V15.88 | | |

| |supplement for those 65 years and older living in | |ICD10 – Z91.81 | | |

| |a community dwelling | | | | |

|Genetic Testing (referral for BRCA |For women with family history of an increased risk|12/01/2014 |ICD9 – V16.3, V82.7 |81211, 81212, 81213, 81214, |Starmark = PLA |

|counseling and evaluation) W |for deleterious mutations in BRCA1 or BRCA2 genes | |ICD10 – Z13.71, Z13.79, Z80.3|81215, 81216, 81217 | |

| |and for women who have had a prior non-BRCA | | | | |

| |related breast or ovarian cancer diagnosis, even | | | | |

| |if currently asymptomatic and cancer-free, | | | | |

| |including BRCA testing if determined appropriate | | | | |

| |by a physician | | | | |

| | | | |99401, 99402, 99403, 99404 |Affinity Markets and Group = RPE |

| | | | | |Starmark = POV |

|Gonorrhea Infection Screening W |Women at increased risk for infection |05/01/2006 |ICD9 – V74.5, V75.9 |87590, 87591, 87592, 87850 |Affinity Markets and Group = RLB, SPL |

| | | |ICD10 – Z11.3, Z11.9 | |Starmark = PLA |

|Healthy Eating Assessment and Dietary |By primary health care provider, nutritionist or |01/01/2004 |ICD9 – V65.3, V65.4 |97802, 97803, 97804, 99201, |Affinity Markets and Group = RPE, SPV |

|Counseling |dietitian for adults at high risk for diet-related| |ICD10 – Z71.3, Z71.89, Z71.9 |99202, 99203, 99204, 99205, |Starmark = POV |

|Note: Assessment is to estimate the |disease | | |99211, 99212, 99213, 99214, | |

|likelihood of adverse effects | | | |99215 | |

|Hepatitis B Screening |Non-pregnant adults |05/01/2014 | | | |

|Hepatitis C Virus Infection Screening |For persons at high risk of infection and adults |06/01/2014 | | | |

| |born between 1945 and 1965 | | | | |

|High Blood Pressure Screening |Adults age 18 and older |12/01/2008 |ICD9 – V81.1 |99201, 99202, 99203, 99204, |Affinity Markets and Group = RPE |

| | | |ICD10 – Z13.6 |99205, 99211, 99212, 99213, |Starmark = POV |

| | | | |99214, 99215 | |

|HIV Infection (Human Immunodeficiency |Adults at increased risk |04/01/2014 |ICD9 – V08 |86689, 86701, 86702, 86703, |Affinity Markets and Group = RLB |

|Virus) Screening | | |ICD10 – Z21 |87390, 87534, 87535, 87536 |Starmark = PLA |

| | | | |S3645 |Affinity Markets, Group and Starmark = RLB |

|Lung Cancer Screening |Annual screening for ages 55 to 80 who have a 30 |12/01/2014 |ICD10 – |G0296, G0297, S8032 | |

| |pack a year smoking history and currently smoke or| |F17.210-F17.219, | | |

| |have quit within the last 15 years | |F17.290-F17.299, Z12.2, | | |

| | | |Z72.0, Z87.891 | | |

|Obesity Screening and Counseling for |Screening for all adults. Referral for counseling|01/01/2013 |ICD9 – 278.0, 278.00, 278.01,|97802, 97803, 97804, 99401, |Affinity Markets and Group = RPE |

|Weight Loss |for adults with BMI of 30 or above. | |278.02, 278.03, V77.8 |99402, 99403, 99404, 99411, |Starmark = POV |

| |The recommendation specifies that intensive, | |ICD10 – E66.01, E66.3, E66.2,|99412, 99420 | |

| |multicomponent behavioral interventions include, | |E66.9, Z13.2, Z68.3-Z68.45 | | |

| |for example, the following: | | | | |

| |Group and individual sessions of high intensity | | | | |

| |(12 to 26 sessions in a year), | | | | |

| |Behavioral management activities, such as | | | | |

| |weight-loss goals, | | | | |

| |Improving diet or nutrition and increasing | | | | |

| |physical activity, | | | | |

| |Addressing barriers to change, | | | | |

| |Self-monitoring, and | | | | |

| |Strategizing how to maintain lifestyle changes. | | | | |

| | | | |98960 |Affinity Markets and Group = OME* |

| | | | | |Starmark = PLA |

| | | | | |*CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

|Osteoporosis Screening (Bone Density |Routine screening for osteoporosis for women age |01/01/2013 |ICD9 – V82.81 |77078, 77079, 77080 |Affinity Markets and Group = RXY |

|Screening) W |65 and older. Beginning at age 60 if at increased| |ICD10 – Z13.820 | |Starmark = PXR |

| |risk for fractures | | | | |

| | | | |99420 |Affinity Markets and Group = RPE |

| | | | | |Starmark = POV |

|Prostate Screening (PSA) M |Once per calendar year age 40 and above |09/23/2010 | |84152, 84153, 84154 |Affinity Markets, Group: |

| | | | | |Routine = RLB, RPP |

| |Note: this is included on this list | | | |Routine with 06 Wellness benefit = SPL |

| |administratively; it is not an HCR requirement. | | | |Non-Routine = LAB, PTH |

| | | | | |Individual Medical: |

| | | | | |Routine = RPE (if nor routine on plan, follow |

| | | | | |medical) |

| | | | | |Non-Routine = LAB, PTH |

| | | | | |Starmark = |

| | | | | |Routine = PLA, PPL |

| | | | | |Non-Routine = LAB, PTH |

|Sexually Transmitted Infection (STI) |1 counseling session to prevent STI’s |10/01/2009 |ICD9 – V65.45 |99401, 99402, 99403, 99404 |Affinity Markets and Group = RPE |

|Counseling | | |ICD10 – Z71.89 | |Starmark = POV |

|Syphilis Infection Screening |For persons at increased risk (no time or age |07/01/2005 |ICD9 – V74.5 |86592, 86593, 86781, |Affinity Markets and Group = RLB |

| |limits) | |ICD10 – Z11.3 |87164, 87166, 87285 |Starmark = PLA |

|Tobacco Use Screening and Interventions |Counseling about tobacco use and provide tobacco |04/01/2011 |ICD9 – 305.1, V15.82 |99401, 99402, 99403, 99404, |Affinity Markets and Group = RPE |

| |cessation interventions |05/02/2014 |ICD10 – F17.200, Z87.891 |99406, 99407, |Starmark = POV |

| |Note: Smoking cessation drugs are not covered | | |G0436, G0437, G9016, | |

| |under HCR. Only the counseling to take the drugs | | | | |

| |is covered. | | | | |

| |Counseling about tobacco use and provide tobacco | | | | |

| |cessation interventions. This includes screening | | | | |

| |for tobacco use and, for those that use tobacco | | | | |

| |products, two tobacco use cessation attempts per | | | | |

| |plan year. | | | | |

| |Note: One cessation attempt includes four | | | | |

| |counseling sessions of 10 minutes or more and all | | | | |

| |FDA approved tobacco cessation drugs (both RX & | | | | |

| |OTC) for a 90-day treatment when prescribed by a | | | | |

| |health care provider. Prior authorization does | | | | |

| |not apply. | | | | |

| | | | |99078 |Affinity Markets, Group = RPE/SPV |

| | | | | |Starmark = POV |

| | | | | |CPT will except out. Requires processor review to |

| | | | | |pay HCR 100% in-network benefit. |

| | | | |S9075, S9453 |Affinity Markets and Group = RPE/SPV |

| | | | | |Starmark = POV |

| | | | | |CPT will except out. Requires processor review to |

| | | | | |pay HCR 100% in-network benefit. |

|Tuberculosis Screening |Asymptomatic adults at increased risk for |08/01/2017 | | | |

| |infection | | | | |

|Screening for Pregnant Women |Services Provided |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|Chlamydia Infection Screening |Pregnant women age 24 and younger and for older |06/01/2008 |ICD9 – V73.88- V73.98, V74.5,|86631, 86632, 87491 |Affinity Markets and Group = RLB/SPL |

| |pregnant women who are at increased risk | |V75.9 | |Starmark = PLA |

| | | |ICD10 – Z11.3, Z11.59, Z11.8,| | |

| | | |Z11.9 | | |

|Folic Acid Supplementation |Coverage for daily supplement |05/01/2010 | |J3490 |Affinity Markets and Group = INJ |

| |Notes: | | | |Starmark = INJ |

| |Prenatal vitamins are covered because they contain| | | |*CPT will except out. Requires processor review to|

| |folic acid | | | |pay HCR 100% in-network benefit. |

| |Prenatal vitamins are covered by CVS Caremark as | | | | |

| |of 10/01/2014 | | | | |

| | | | |99401, 99402, 99403, 99404 |Affinity Markets and Group = RPE/SPV |

| | | | | |Starmark = POV |

|Hepatitis B Infection Screening |At first prenatal visit, with diagnosis of |06/01/2010 |ICD9 – V02.61 |87340 |Affinity Markets and Group = RLB |

| |pregnancy | |and a pregnancy diagnosis | |Starmark = PLA |

| | | |ICD10 – Z22.51 | | |

| | | |and a pregnancy diagnosis | | |

|HIV Infection Screening |For all pregnant women |04/01/2014 | | | |

|Iron Deficiency Anemia |With a diagnosis of pregnancy |09/23/2010 – |ICD9 – V78.0 |85013, 85014, 85018 |Affinity Markets and Group = RLB |

|(09/23/2010 – 01/01/2018) |(09/23/2010 – 01/01/2018) |01/01/2018 |ICD10 – Z13.0 | |Starmark = PLA |

|Prenatal Office Visits |Prenatal care must be covered at 100% regardless |new and renewing| |59425, 59426 |Affinity Markets and Group = RPE/SPV |

| |if maternity coverage is on the plan. |plans on or | | |Starmark = POV |

| | |after 01/01/2014| | |*CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit |

|Rh (antibody) Incompatibility Testing |At 12-16 weeks gestation (or at first prenatal |02/01/2005 |ICD9 – V22.0, V22.1 |86901 |Affinity Markets and Group = RLB/SPL |

| |visit, if later) and at 24-28 weeks gestation | |ICD10 – Z34.00, Z34.80, | |Starmark = PLA |

| | | |Z34.90 | | |

|Syphilis Testing |For all pregnant women (no time or age limits) |05/01/2010 |ICD9 – V73.88- V73.98, V74.5,|86592, 86593 |Affinity Markets and Group = RLB |

| | | |V75.9 | |Starmark = PLA |

| | | |ICD10 – Z11.3, Z11.59, Z11.8,| | |

| | | |Z11.9 | | |

| | | | |G0450 |Affinity Markets and Group = RPE/CRV |

| | | | | |Starmark = POV |

|Tetanus, Diptheria, Pertussis (TDaP) |1 dose during pregnancy, regardless of when last |06/07/2016 | | | |

| |dosed, then follow Adult Immunizations | | | | |

|Tobacco Use Screening and Interventions |Pregnancy-tailored counseling for those who smoke | |ICD9 – 305.1, V15.82 |99401, 99402, 99403, 99404, |Affinity Markets and Group = RPE |

| | | |ICD10 – F17.200, Z87.891 |99406, 99407, |Starmark = POV |

| | | | |G0436, G0437, G9016 | |

|Urine Culture for Bacteriuria |Limited to one test per pregnancy |07/01/2009 |ICD9 – V47.4 |87081, 87086 |Affinity Markets and Group = RLB |

| | | |and a pregnancy code | |Starmark = PLA |

| | | |ICD10 – R68.89 | | |

| | | |and a pregnancy code | | |

|Adult immunizations |Services Provided |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|Hepatitis A |For those at risk (2 doses) |09/23/2010 | |90632, 90633, 90634, 90636 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Hepatitis B |For those at risk (3 doses) |09/23/2010 | |90731, 90740, 90746 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Non-Routine = INJ |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = |

| | | | | |Routine = PIM |

| | | | | |Therapeutic (non-routine) = INJ |

|Herpes Zoster (Shingles) |After age 60 (1 dose) |09/23/2010 | |90736 |Affinity Markets, Group, Individual Medical = IMM |

| |Administratively, Trustmark will follow the FDA |02/01/2016 | | |Starmark = PIM |

| |guidelines and allow beginning at age 50 | | | | |

|Human Papillomavirus (HPV) |Ages 18-26 (3 doses) |09/23/2010 | |90649, 90650 |Affinity Markets, Group, Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Influenza (Flu) |Annually |09/23/2010 | |90655, 90656, 90657, 90658, |Affinity Markets, Group, Individual Medical: |

| | | | |90660, 90662 |Routine = IMM |

| | | | | |Non-Routine = INJ |

| | | | | |Starmark: |

| | | | | |Routine = PIM |

| | | | | |Non-Routine = INJ |

|Measles, Mumps, Rubella |1-2 doses from age 19-58 |09/23/2010 | |90705, 90707, 90708, 90710 |Affinity Markets, Group: |

| |Note: people born before 1957 are immune to | | | |Routine = IMM |

| |measles, mumps | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Meningococcal |For those at risk (1 or more doses) |09/23/2010 | |90733, 90734, 90466, 90620, |Affinity Markets, Group: |

| | | | |90664 |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Pneumococcal |For those at risk (1 or 2 doses), After age 65 (1 |09/23/2010 | |90669, 90732 |Affinity Markets, Group: |

| |dose) | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Tetanus, Diphtheria, Pertussis (TDaP) |1 dose, then every 10 years |09/23/2010 |ICD9 – V03.7, V06.1, V06.5 |90700, 90701, 90702, 90703 |Affinity Markets, Group, Individual Medical = IMM |

| | | |ICD10 – Z23 | |Starmark = PIM |

|Varicella (Chickenpox) |2 doses |09/23/2010 | |90716 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = |

| | | | | |CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

Essential Preventive Health Services for Children and Teens

The following information pertains to any plans effective September 23, 2010 or later, as well as non-grandfathered plans, and grandfathered plans with this election. The routine exams, immunizations and screenings for children under age 22 listed below are covered in full when received from a provider within the plan’s network. This list is not all-inclusive; however, it is to be used as a guideline for allowing benefits. Any code NOT on this list must be reviewed by the Medical Director before allowing at the HCR 100% benefit. Services may vary by plan/state. When a service does not mention a frequency, there is no limit; however, it is subject to medical necessity.

|Well Child Exams / Health Screenings |Services Schedule |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|for: | | | | | |

|Exams for Age 4 – 21 Years |Annually ages 4-21 |09/23/2010 |ICD9 – V20.2 |99383, 99384, 99391, 99392, |Affinity Markets and Group = RPE |

| | | |ICD10 – Z0012, |99393, 99394 |Starmark = POV |

| | | |Z00.121, Z00.129 | | |

|Alcohol and Drug Use |Risk assessment beginning at age 11 |09/23/2010 |ICD9 – 304, 305.0, |90804 |Affinity Markets, Group and Starmark = PFP |

| | | |V79.1 | |CPT will except out. Requires processor review to|

| |Note: Assessment is to estimate the likelihood of adverse | |ICD10 – F10.10, | |pay HCR 100% in-network benefit. |

| |effects | |F10.120, F10.129, | | |

| | | |F11-F19, Z13.89 | | |

| | | | |96150, |Affinity Markets & Group = PTE* |

| | | | |G0442, G0444 |Starmark = POV |

| | | | | |*CPT will except out. Requires processor review |

| | | | | |to pay HCR 100% in-network benefit. |

| | | | |98960 |Affinity Markets & Group = OME |

| | | | | |Starmark = PLA |

| | | | | |CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

| | | | |99384, 99385, 99386, 99387, |Affinity Markets & Group = RPE |

| | | | |99394, 99395, 99396, 99397, |Starmark = POV |

| | | | |99401, 99402, 99420 | |

| | | | |H0001 |Affinity Markets & Group = NCS |

| | | | | |Starmark = NCS |

| | | | | |CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

| | | | |H0049 |Affinity Markets & Group = NCS |

| | | | | |Starmark = NCS |

| | | | | |CPT will except out. Requires processor review to|

| | | | | |pay HCR 100% in-network benefit. |

|Autism |18 months, 24 months |09/23/2010 | | | |

|Behavioral Problems |Newborn, 3-5 days, 1, 2, 4, 6, 9, 12, 15, 18, 24, 30 |09/23/2010 |ICD10 – Z13.89, Z13.4 |90899, 96127, 96150-96155, | |

| |months, then annually ages 3-21 | | |Also any E/M code | |

| |Note:  provides a Pediatric | | | | |

| |Symptom Checklist to help aid providers in these required | | | | |

| |services. Per the Pediatric Symptom Checklist-17 (PSC-17) | | | | |

| |a psychosocial screen is designed to facilitate the | | | | |

| |recognition of cognitive, emotional, and behavioral | | | | |

| |problems so appropriate interventions can be initiated as | | | | |

| |early as possible. | | | | |

|Cervical Abnormalities (PAP Smear and |Risk assessment beginning at age 11 |09/23/2010 |ICD9 – V76.2, V72.3 |88141, 88142, 88143, 88144, |Affinity Markets and Group = SPL |

|HPV Testing) | | |ICD10 – Z01.411, |88145, 88146, 88147, 88148, |Starmark = PLA |

| |Note: Assessment is to estimate the likelihood of adverse | |Z01.419, Z12.4 |88149, 88150, 88151, 88152, | |

| |effects | | |88153, 88154, 88155, 88164, | |

| | | | |88165, 88166, 88174, 88175, | |

| | | | |Q0091 | |

| | | | |88167 |Affinity Markets and Group = RLB |

| | | | | |Starmark = PLA |

|Depression Screening |Ages 12-18 |03/01/2010 |ICD9 – V79.0 |99420 |Affinity Markets and Group = RPE |

| | | |ICD10 – Z13.89 | |Starmark = POV |

|Developmental Problems |Newborn, 3-5 days, 1, 2, 4, 6, 12, 15, 24 months, then |09/23/2010 | |96110, 96111 |Affinity Markets and Group = RPE |

| |annually ages 3-21 | | | |Starmark = POV |

|Gonorrhea Medication |Prophylactic medication for newborns |07/01/2012 |ICD9 – V20.0, V20.31, | | |

| | | |V20.32 | | |

| | | |ICD10 – Z00.110, | | |

| | | |Z00.111, Z76.1 | | |

|Hearing Screening |Newborn, Ages 4, 5, 6, 8, 10 |07/01/2009 |ICD9 – V20.2, V20.3, |92585, 92586, 92587, 92588 |Affinity Markets and Group = RLB |

| | | |V20.31, V20.32 | |Starmark = PLA* |

| | | |ICD10 – Z00.110, | |*When billed with POS H, use switch codes as |

| | | |Z00.111, Z00.129 | |follows: |

| | | | | |PPO: |

| | | | | |A01 - All other Networks |

| | | | | |P01 - PHCP |

| | | | | |Non-PPO:  switch code is based on coinsurance % |

| | | | | |N50 - 50% |

| | | | | |N60 - 60% |

| | | | | |N70 - 70% |

|Height, Weight and Body Mass Index |Newborn, 3-5 days, 1, 2, 4, 6, 9, 12, 15, 18, 24, 30 |09/23/2010 | | | |

|(BMI) |months, then annually ages 3-21 | | | | |

|Hepatitis B Screening |Non-pregnant adolescents |Plan years on or| | | |

| | |after 01/01/2015| | | |

|HIV (human immunodeficiency virus) |Adolescents at increased risk |09/23/2010 |ICD9 – V08 |86689, 86701, 86702, 86703, |Affinity Markets and Group = RLB |

| | | |ICD10 – Z21 |87390, 87534, 87535, 87536 |Starmark = PLA |

| | | | |S3645 |Affinity Markets, Group and Starmark = RLB |

|Hypothyroidism - Congenital (Lack of |Newborn |03/01/2009 |ICD9 – V20.3, V20.31, | | |

|Thyroid Secretions) | | |V20.32 | | |

| | | |ICD10 – Z00.110, | | |

| | | |Z00.111 | | |

|Iron Supplement |Prescription strength iron supplementation of any type when|05/01/2007 – |ICD9 – V20.2, V78.0 | | |

|(05/01/2007 – 01/01/2018) |used to prevent or treat iron deficiency anemia in children|01/01/2018 |ICD10 – Z00.129, Z13.0| | |

| |age 6 to 12 months | | | | |

| |(05/01/2007 – 01/01/2018) | | | | |

|Lead Screening |12 and 24 months, risk assessment 6 months-age 6 |09/23/2010 | |83655 |Affinity Markets, Group and Starmark: |

| | | | | |Routine = RLB |

| |Note: Assessment is to estimate the likelihood of adverse | | | |Non-Routine = LAB |

| |effects | | | |Individual Medical: |

| | | | | |Routine – If routine labs not in policy, manually |

| | | | | |exclude |

| | | | | |Non-Routine = LAB |

|Lipid Disorders (Cholesterol and |Ages 18-21, Risk assessment ages 2, 4, 8, annually ages |09/23/2010 | | | |

|Triglycerides) |10-17 | | | | |

| |Note: Assessment is to estimate the likelihood of adverse | | | | |

| |effects | | | | |

|Obesity Screening and Counseling to |For ages 6 and older |01/01/2011 |ICD9 – 278-278.03, |97802, 97803, 97804, 99401, |Affinity Markets and Group = RPE |

|Improve Weight | | |V77.8 |99402, 99403, 99404, 99411, |Starmark = POV |

| | | |ICD10 – E66.01, E66.2,|99412, 99420 | |

| | | |E66.3, E66.9, Z13.2, | | |

| | | |Z68.3-Z68.45 | | |

| | | | |98960 |Affinity Markets and Group = OME* |

| | | | | |Starmark = PLA |

| | | | | |*CPT will except out. Requires processor review |

| | | | | |to pay HCR 100% in-network benefit. |

|Oral Health Assessment |Oral fluoride supplementation at currently recommended |04/01/2005 | |99188 | |

|Note: Assessment is to estimate the |doses to preschool children older than 6 months of age | | | | |

|likelihood of adverse effects | | | | | |

|PKU (Phenylketonuria – An Inherited |Newborn |03/01/2009 |ICD9 – V77.3 |84030 | |

|Metabolic Deficiency) | | |ICD10 – Z13.228 | | |

|Sexually Transmitted Infection (STI) |Counseling sessions to prevent STIs for all sexually active|10/01/2009 |ICD9 – V65.45 |99401, 99402, 99403, 99404 |Affinity Markets and Group = RPE |

|Prevention Counseling |adolescents | |ICD10 – Z71.89 | |Starmark = POV |

|Sickle Cell Anemia and Trait |Newborn |09/01/2008 | | | |

|(Hemoglobinopathies) | | | | | |

|Skin Cancer Counseling |For ages 10 – 24 |05/01/2013 | | | |

|Tuberculin Testing |Risk assessment 1, 6, 12, 18, 24 months, then annually ages|09/23/2010 |ICD9 – V01.1, V03.2, |86480, 86481, 86580 |Affinity Markets and Group = RLB |

| |3-21 | |V74.1 | |Starmark = PLA |

| |Note: Assessment is to estimate the likelihood of adverse | |ICD10 – Z11.1, Z20.1, | | |

| |effects | |Z23 | | |

|Visual Acuity Screening |One time between the ages of 3 and 5 to detect presence of |01/01/2012 | | | |

| |amblyopia | | | | |

|Vision Screening |Two times per year for newborns and well-child visits |09/23/2010 |ICD9 – V72.0 |92081 |Affinity Markets and Group = VSC |

| |Risk assessment ages 7, 9, 11, 13, 14, 16 , 17, 19, 20, 21 | |ICD10 – Z01.00, Z01.01| |Starmark = PLA |

| |Screening Ages 3, 4, 5, 6, 8, 10, 12, 15, 18 | | | | |

| | | | | | |

| |Note: Assessment is to estimate the likelihood of adverse | | | | |

| |effects | | | | |

| | | | |92082, 92083 |Affinity Markets and Group = VSC |

| | | | | |Starmark = PXR |

| | | | |92002, 92004, 92012, 92014 |Affinity Markets and Group = VSC* |

| | | | | |Starmark = POV |

| | | | | |*CPT will except out. Requires processor review |

| | | | | |to pay HCR 100% in-network benefit. |

| | | | |99172, 99173, 99174 |Affinity Markets and Group = OME* |

| | | | | |Starmark = POV |

| | | | | |*CPT will except out. Requires processor review |

| | | | | |to pay HCR 100% in-network benefit. |

|Immunizations |Services Provided |Effective Date |Diagnosis Code(s) |Procedure Code(s) |TOS Code(s) |

|Flu (Influenza) |1 or 2 doses starting at 6 months-8 years |09/23/2010 | |90655, 90657, 90658, |Affinity Markets, Group, Individual Medical: |

| |1 dose annually at 9 years | | |90660, 90662 |Routine = IMM |

| | | | | |Non-Routine = INJ |

| | | | | |Starmark: |

| | | | | |Routine = PIM |

| | | | | |Non-Routine = INJ |

|Haemophilus influenza type B (HIB) |2 months, 4 months, 6 months, between 15-18 months |09/23/2010 | |90644, 90645, 90646, |Affinity Markets, Group: |

| | | | |90647, 90648 |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Hepatitis A |Between 12 and 23 months (2 doses) |09/23/2010 | |90632, 90633, 90634, |Affinity Markets, Group: |

| | | | |90636 |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Hepatitis B |Birth, between 1 and 2 months, between 6-18 months |09/23/2010 | |90731, 90740, 90746 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Non-Routine = INJ |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = |

| | | | | |Routine = PIM |

| | | | | |Therapeutic (non-routine) = INJ |

|HPV (Human Papilloma Virus) |Between 11-12 years (3 doses |09/23/2010 | |90649, 90650 |Affinity Markets, Group, Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Measles, Mumps, Rubella (MMR) |12-15 months, 4-6 years |09/23/2010 | |90705, 90707, 90708, |Affinity Markets, Group: |

| | | | |90710 |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Meningococcal |11-12 years, booster at 16 years |09/23/2010 | |90733, 90734, 90466, |Affinity Markets, Group: |

| | | | |90620, 90664 |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Pneumococcal (PCV) |2, 4, 6 months, then 12-15 months |09/23/2010 | |90669, 90732 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Inactivated Polio |2, 4, 6-18 months, then 4-6 years |09/23/2010 | |90712, 90713 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Rotavirus |2 months, 4 months, 6 months (Rotateq) 2 months, 4 months |09/23/2010 | |90680, 90681 |Affinity Markets, Group: |

| |(Rotarix) | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

|Varicella (Chickenpox) |Between 12-15 months, between 4-6 years |09/23/2010 | |90716 |Affinity Markets, Group: |

| | | | | |Routine = IMM |

| | | | | |Routine for children on plans with 06 wellness = CIM |

| | | | | |Individual Medical = IMM |

| | | | | |Starmark = PIM |

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