In-Network Wellness Care (For Consumer HDHP, Enhanced HDHP and Base PPO in accordance with plan provisions.)
Newborn to
less than 3 years
3 years to
less than 7 years
7 years to
less than 13 years
13 years to
less than 22 years
22 years to
less than 40 years
40 years to
less than 50 years
Exams
Height/weight
Physical
Routine developmental
testing
Screening for visual acuity
Obesity prevention
counseling
Height/weight
Blood pressure
Physical & psychosocial
developmental assessment
Screening for visual acuity
Obesity prevention
counseling
Height/weight
Blood pressure
Physical & psychosocial
developmental assessment
Obesity prevention
counseling
Height/weight
Blood pressure
Physical & psychosocial
developmental/mental
assessment
Scoliosis check
Clinical testicular exam
Clinical breast exam
Complete skin exam if
performed by PCP or
Dermatologist as routine
Gynecological exam (age 18 or
onset of sexual activity)
Obesity prevention counseling
Alcohol misuse assessment
Tobacco use assessment
Well-woman visits to include:
● Gestational diabetes
screening
● Human papillomavirus
(HPV) test
● Sexually transmitted
infections counseling
● human immunodeficiency
virus (HIV) screening and
counseling
● FDA – approved
contraception methods and
contraceptive counseling
● Interpersonal and domestic
violence screening and
counseling
Breastfeeding support, supplies
and counseling
● Support and counseling
during pregnancy and/or
post-partum period
● Breastfeeding equipment
Height/weight
Blood pressure
Physical & mental status
assessment
Clinical breast exam
Clinical testicular exam
Complete skin exam if
performed by PCP or
Dermatologist as routine
Gynecological (annually)
Obesity prevention counseling
Alcohol misuse assessment
Tobacco use assessment
Well-woman visits to include:
● Gestational diabetes
screening
● Human papillomavirus
(HPV) test
● Sexually transmitted
infections counseling
● human immunodeficiency
virus (HIV) screening and
counseling
● FDA – approved
contraception methods and
contraceptive counseling
● Interpersonal and domestic
violence screening and
counseling
Breastfeeding support, supplies
and counseling
● Support and counseling
during pregnancy and/or
post-partum period
● Breastfeeding equipment
Height/weight
Blood pressure
Physical & mental status
assessment
Clinical breast exam
Clinical testicular exam
Complete skin exam if
performed by PCP or
Dermatologist as routine
Gynecological (annually)
Obesity prevention counseling
Alcohol misuse assessment
Tobacco use assessment
Well-woman visits to include:
● Gestational diabetes
screening
● Human papillomavirus
(HPV) test
● Sexually transmitted
infections counseling
● human immunodeficiency
virus (HIV) screening and
counseling
● FDA – approved
contraception methods and
contraceptive counseling
● Interpersonal and domestic
violence screening and
counseling
Breastfeeding support, supplies
and counseling
● Support and counseling
during pregnancy and/or
post-partum period
● Breastfeeding equipment
Height/weight
Blood pressure
Physical & mental status
assessment
Clinical breast exam
Clinical testicular exam
Complete skin exam if
performed by PCP or
Dermatologist as routine
Gynecological (annually)
Screening for abdominal aortic
aneurysm (one time
ultrasonography)
Obesity prevention counseling
Alcohol misuse assessment
Tobacco use assessment
Well-woman visits to include:
● Gestational diabetes
screening
● Human papillomavirus
(HPV) test
● Sexually transmitted
infections counseling
● human immunodeficiency
virus (HIV) screening and
counseling
● FDA – approved
contraception methods and
contraceptive counseling
● Interpersonal and domestic
violence screening and
counseling
Breastfeeding support, supplies
and counseling
● Support and counseling
during pregnancy and/or
post-partum period
● Breastfeeding equipment
Pharmacy
Oral fluoride (Rx only - age
6 months thru 6 years)
Iron supplements (ages 6
months through 12 months)
(Rx and OTC)
Oral fluoride (Rx only - age
6 months thru 6 years)
Folic Acid (Women to age 55 OTC only)
Tobacco cessation (Rx and
OTC)
Aspirin to prevent
cardiovascular disease (OTC)
(men and women over age 45))
Folic Acid (Women to age 55 OTC only)
Tobacco cessation (Rx and
OTC)
Aspirin to prevent
cardiovascular disease (OTC)
(men and women over age 45)
Tobacco cessation (Rx and
OTC)
Vitamin D for falls prevention
(over age 64)
When over-thecounter (OTC)
products are
approved, Rx are
required.
Page 1 of 2
Age 50 and Over
In-Network Wellness Care (For Consumer HDHP, Enhanced HDHP and Base PPO in accordance with plan provisions.)
Newborn to
less than 3 years
3 years to
less than 7 years
7 years to
less than 13 years
13 years to
less than 22 years
Immunizations
Varicella
DPT or DtaP
OPV or IPV
MMR
Rotavirus
Haemophilus influenza
Type b (HIB)
Hepatitis A
Hepatitis B
Tetramune (in lieu of DPT &
HIB)
TriHIBit (combines HIB and
DtaP)
Prevnar/Prevenar
Influenza
Varicella (if not done
earlier) DPT or DtaP
OPV or IPV
MMR
Hepatitis B (if not done
earlier)
Influenza
Hepatitis A (risk factors)
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
vaccine
Prevnar/Prevenar
Varicella (if not done
earlier) MMR (if 2nd dose
not given earlier)
Hepatitis B (if not given
earlier)
Tetanus-Diptheria (Td)
booster
Influenza
Hepatitis A (risk factors)
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
vaccine (risk factors)
HPV vaccine
Varicella (if not done earlier)
Hepatitis B (if not done earlier)
Tetanus-Diptheria (Td) booster
Influenza
Hepatitis A
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
Vaccine
Lyme Disease Vaccine
HPV vaccine
Tetanus-Diptheria
MMR (high risk)
Varicella (if no history of
chicken pox)
Hepatitis B
Influenza
Hepatitis A
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
vaccine
Lyme Disease vaccine (risk
factors)
HPV vaccine
Tetanus-Diptheria (
Varicella (if no history of
chicken pox)
Hepatitis B (high risk if not done
before)
Influenza
Hepatitis A (risk factors)
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
vaccine
Lyme Disease vaccine (risk
factors)
Tetanus-Diptheria
Varicella (if no history of
chicken pox)
Hepatitis B (high risk if not done
before)
Influenza
Hepatitis A (risk factors)
Pneumovax, Pnu-immune
Meningococcal (Meningitis)
vaccine
Lyme Disease vaccine (risk
factors)
Shingles vaccine
Lab/Testing
Vision & hearing screening
Lead screening
Hemoglobin & Hematocrit
Metabolic
Hemoglobinopathies
Tuberculin test
Risk-based
testing/screening:
● Lead screening
● Tuberculin screening
Urinalysis screening
Vision & hearing screening
Hemoglobin & Hematocrit
Tuberculin skin test (if not
done earlier or required by
school)
HIV testing
Risk-based
testing/screening:
● Lead screening
● Lipoprotein profile
(Chol/HDL/LDL/Trig)
● Tuberculin testing
Urinalysis screening
Vision & hearing screening
Hemoglobin & Hematocrit
Tuberculin skin test (if not
done earlier)
HIV testing
High-risk testing/screening:
● Lipoprotein profile
(Chol/HDL/LDL/Trig)
● Tuberculin testing
Urinalysis screening
Vision & hearing screening
Pap Smear (annually – see
above gyn)
Hemoglobin & Hematocrit
Tuberculin skin test (if not done
earlier)
HIV testing
High-risk testing/screening:
● Lipoprotein profile
(Chol/HDL/LDL/Trig)
● Tuberculin testing
● Chlamydia Trachomatis
Lipoprotein profile
(Chol/HDL/LDL/Trig) (every 5
yrs)
Urinalysis screening
Pap Smear (annually)
HPV DNA test (age 30 and
over; every 3 years, when done
in conjunction with Pap Smear)
Mammogram (Baseline at 35
years)
Hemoglobin & Hematocrit
Digital rectal exam
Stool for Occult Blood HIV
testing
Fasting plasma glucose
High risk testing/screening:
● Clamydia Trachmomatis
● Tuberculin Testing
● Bone mineral density
screening
Lipoprotein profile
(Chol/HDL/LDL/Trig) (every 5
yrs)
Urinalysis screening
Pap smear (annually)
HPV DNA test
Mammogram
Hemoglobin & Hematocrit
Digital rectal exam
Stool for Occult Blood
Baseline for EKG
PSA (Prostate Specific Antigen)
Diabetes Mellitus test
High-risk testing/screening:
● Bone mineral density
screening
● Tuberculin Testing
Lipoprotein profile
(Chol/HDL/LDL/Trig) (every 5
yrs)
Urinalysis screening
Pap smear (annually)
HPV DNA test
Mammogram (annually)
Hemoglobin & Hematocrit
Digital rectal exam
Stool for Occult Blood
Double-contrast barium enema
Baseline for EKG
PSA (Prostate Specific Antigen)
Sigmoidoscopy or Colonoscopy
All are covered,
including but not
limited to:
Page 2 of 2
22 years to
less than 40 years
40 years to
less than 50 years
Age 50 and Over
HIV Testing
Diabetes Mellitus Test
High-risk testing/screening:
● Bone mineral density
screening (once every 2
years)
● Tuberculin testing