-
Service Type Benefit Description Procedure Codes LOB Limitations
ExclusionsIn Network Authorization
Required
Out-of-Network Authorization
RequiredRN Review Required
CMA to MD direct
(bypass RN input)
RN to Determine
Status (no MD input)Just Say Yes' by CMAs No Auth Required
Out of Network Treated as In
NetworkAlways Say No By CMAs Delegated to External Vendor
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): A participating Physician
who typically is an internal medicine or family practice
Physician and who directly provides or coordinates a
range of health care services for You. Covered in full
Specialist: A Physician who focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and conditions
Covered in full
99201-99215
99241-99245
99341-99350
MedicaidHome MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standards
Y-PRENATAL OUT OF NETWORK (2 &
3 TRIMESTER ONLY-13+ WEEKS
GESTATION)
IN NETWORKMONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $15 Copayment
Medication given in PCP Office $15 Copayment
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $25 Copayment
Medication given in Specialist Office $25 Copayment
99201-99215
99241-99245
99341-99350
Essential Plan 1
Non-Aliessa
Home MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO Y Y-ALL
OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $0 No Cost Sharing
Medication given in PCP Office $0 No Cost Sharing
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $No Cost Sharing
Medication given in Specialist Office $0 No Cost Sharing
99201-99215
99241-99245
99341-99350
Essential Plan 2
Non-Aliessa
Home MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO Y Y-ALL
OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit Covered in full
Medication given in PCP Office Covered in full
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office Covered in full
Medication given in Specialist Office Covered in full
99201-99215
99241-99245
99341-99350
Essential Plan 3/4
Aliessa
Home MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): A participating Physician
who typically is an internal medicine or family practice
Physician and who directly provides or coordinates a
range of health care services for You. Covered in full
Specialist: A Physician who focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and conditions
Covered in full
99201-99215
99241-99245
99341-99350
Child Health PlusHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO Y Y-ALL
OUT OF NETWORK IN NETWORK
MONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): A participating Physician
who typically is an internal medicine or family practice
Physician and who directly provides or coordinates a
range of health care services for You. Covered in full
Specialist: A Physician who focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and conditions
Covered in full
99201-99215
99241-99245
99341-99350
MetroPlus Enhanced
(HARP)
Home MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standards
Y-PRENATAL OUT OF NETWORK (2 &
3 TRIMESTER ONLY-13+ WEEKS
GESTATION)
IN NETWORKMONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): A participating Physician
who typically is an internal medicine or family practice
Physician and who directly provides or coordinates a
range of health care services for You. Covered in full
Specialist: A Physician who focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and conditions
Covered in full
99201-99215
99241-99245
99341-99350
HIV Special NeedsHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standards
Y-PRENATAL OUT OF NETWORK (2 &
3 TRIMESTER ONLY-13+ WEEKS
GESTATION)
IN NETWORKMONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $0 Copayment
Medication given in PCP Office $0 Copayment
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $0 Copayment
Medication given in Specialist Office $0 Copayment
99201-99215
99241-99245
99341-99350
MetroPlus GoldHome MD Visits - Must meet Medicare's definition
of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $20 Copayment
Medication given in PCP Office included in PCP copay
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $40 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
2020 BENEFITS SUMMARY UM Requirements Details
The list of procedure codes on this grid is provided for
reference purposes only. These codes may not be all inclusive, and
listing of a code shall not imply that the service type described
by the procedure code is a covered benefit or non-covered benefit.
The inclusion of a procedure code does not
guarantee claim reimbursement. Please refer to the member plan
benefit or handbook for a specific coverage of the service.
NON-PARTICIPATING PROVIDER SERVICES ARE NOT COVERED AND MEMBER IS
RESPONSIBLE FOR ALL COSTS.
-
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $10 Copayment
Medication given in PCP Office included in PCP copay
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $20 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IA Home MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $10 Copayment
Medication given in PCP Office included in PCP copay
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $20 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IB Home MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $30 Copayment
Medication given in PCP Office included in PCP copay
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $50 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IIHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $15 Copayment
Medication given in PCP Office included in PCP copay
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $30 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IIA Home MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
PCP Office Visit $15 Copayment
Medication given in PCP Office included in PCP copay
Specialist Office $30 Copayment
Medication given in Specialist Office included in Specialist
copay
99201-99215
99241-99245
99341-99350
MetroPlus GoldCare IIB Home MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
3 PCP office visits with $0 copayment not subject to
deductible; subsequent visits 0% coinsurance after
deductible (see limitations)
Medication given in PCP Office 0% Coinsurance after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
0% Coinsurance after deductible
Medication given in Specialist Office 0% Coinsurance after
deductible
99201-99215
99241-99245
99341-99350
MedPlus
Catastrophic
3 PCP Office Visits with $0 Copayments not subject to
deductible; subsequent visits covered in full after
deductible. Home MD Visits - Must meet
Medicare's definition of homebound, which means leaving
home is a major effort
NOY - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit 50% Coinsurance after deductible
Medication given in PCP Office 50% Coinsurance after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office 50% Coinsurance after deductible
Medication given in Specialist Office 50% Coinsurance
after deductible
99201-99215
99241-99245
99341-99350
BronzePlus
3 PCP Office Visits with $0 Copayments not subject to
deductible; subsequent visits covered in full after
deductible. Home MD Visits - Must meet
Medicare's definition of homebound, which means leaving
home is a major effort
NOY - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $30 Copayment after deductible
Medication given in PCP Office $30 Copayment after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $50 Copayment after deductible
Medication given in Specialist Office $50 Copayment after
deductible
99201-99215
99241-99245
99341-99350
SilverPlusHome MD Visits - Must meet Medicare's definition
of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $25 Copayment after deductible
Medication given in PCP Office $25 Copayment after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $40 Copayment after deductible
Medication given in Specialist Office $40 Copayment after
deductible
99201-99215
99241-99245
99341-99350
GoldPlusHome MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
-
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $15 Copayment
Medication given in PCP Office $15 Copayment
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $35 Copayment
Medication given in Specialist Office $35 Copayment
99201-99215
99241-99245
99341-99350
PlatinumPlusHome MD Visits - Must meet Medicare's definition
of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $0 Copayment
Medication given in PCP Office 20% of cost Part B drugs
Part D based on your Deductible and Plan
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $40 Copayment
Medication given in Specialist Office 20% of cost Part B
drugs Part D based on your Deductible and Plan
99201-99215
99241-99245
99341-99350
Medicare PlatinumHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortYes - Home
MD visit Y
Y-ALL OUT OF NETWORK Y-
Home MD visitIN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT);
MONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit 0% OR 20% of cost
Medication given in PCP Office 20% of cost Part B drugs
Part D based on your Deductible and Plan
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office 0% OR 20% of cost
Medication given in Specialist Office 20% of cost Part B
drugs Part D based on your Deductible and Plan
99201-99215
99241-99245
99341-99350
Medicare AdvantageHome MD Visits - Must meet Medicare's
definition of
homebound, which means leaving home is a major effortYes - Home
MD visit Y
Y-ALL OUT OF NETWORK Y-
Home MD visitIN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT);
MONTEFIORE MEDICAL CENTER-
SPECIALIST ONLY NO PCP
1
OFFICE/HOME VISITS
PCP
SPECIALIST
NOT COVEREDMetroPlus Managed Long Term
Care (MLTC)NOT COVERED
Medical benefits, for
instance, Doctor's visits,
emergency room care, and
hospitalization are not
covered by MetroPlus
Managed Long Term Care.
N/A N/A N/A
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit 50% Coinsurance after deductible
Medication given in PCP Office 50% Coinsurance after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office 50% Coinsurance after deductible
Medication given in Specialist Office 50% Coinsurance
after deductible
99201-99215
99241-99245
99341-99350
BronzePlus HSAHome MD Visits - Must meet Medicare's definition
of
homebound, which means leaving home is a major effortNO
Y - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
Medication given in PCP Office $35 Copayment after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $55 Copayment after deductible
Medication given in Specialist Office $55 Copayment after
deductible
99201-99215
99241-99245
99341-99350
SilverPrime
PCP Office Visits: •$35 Copayment (first 3 visits
to PCP or Outpatient Mental Health Care not subject to
Deductible)
•After 3 visits, $35 Copayment after Deductible.
Home MD Visits - Must meet Medicare's definition of
homebound, which means leaving home is a major effort
NOY - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
1
OFFICE/HOME VISITS
PCP
SPECIALIST
Primary Care Physician (“PCP”): Typically an internal
medicine or family practice Physician and who directly
provides or coordinates health care services
PCP Office Visit $25 Copayment after deductible
Medication given in PCP Office $25 Copayment after
deductible
Specialist: A Physician who focuses on a specific area of
medicine to treat (cardiology, geriatrics, psychiatry)
Specialist Office $40 Copayment after deductible
Medication given in Specialist Office $40 Copayment after
deductible
99201-99215
99241-99245
99341-99350
GoldPrime
The first 3 visits to PCP, Outpatient Mental Health Care or
Outpatient Substance Use Services not subject to
deductible); after 3 visits, $25 copayment after
deductible. Home MD Visits - Must meet
Medicare's definition of homebound, which means leaving
home is a major effort
NOY - Follow Medicare coverage
standardsY-ALL OUT OF NETWORK IN NETWORK
MT. SINAI SYSTEMS (MT. SINAI OF
QUEENS, BETH ISRAEL, BETH
ISRAEL KINGS HWY, NY EYE &
EAR, ST. LUKES, ROOSEVELT)
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Medicaid
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Adult)
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Essential Plan 1
Non-Aliessa
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Well-Baby and Well-Child
Care Are Not CoveredY-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN
NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Adult)
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Essential Plan 2
Non-Aliessa
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Well-Baby and Well-Child
Care Are Not CoveredY-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN
NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Adult)
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Essential Plan 3/4
Aliessa
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Well-Baby and Well-Child
Care Are Not CoveredY-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN
NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child)
One (1) visit per calendar year which consists of:
•Well Child visits in accordance with the visitation
schedule established by the American Academy of
Pediatrics •Nutrition Education and Counseling
•Hearing testing
•Medical Social Services
•Eye screening
•Routine immunizations in accordance with those
recommended by the Advisory Committee on
Immunization Practices
•Tuberculin testing
•Dental and developmental screening
•Clinical Laboratory and radiological testing
•Lead Screening
**For the purpose of promoting good health and early
detection of disease. Preventive services are not subject
to Cost-Sharing, Copayments or Coinsurance when
performed by a Participating Provider and provided in
accordance with the comprehensive guidelines supported
by the Health Resources and Services Administration
(HRSA), or if the items or services have an "A" or "B"
rating from the United States Preventive Task Force
(USPSTF), or if the immunizations are recommended by
the Advisory Committee on Immunization Practices
(ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Child Health Plus
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus Enhanced
(HARP)
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
HIV Special Needs
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus Gold
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare I
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare IA
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare IB
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare II
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare IIA
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MetroPlus GoldCare IIB
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
MedPlus
Catastrophic
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
BronzePlus
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
SilverPlus
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
GoldPlus
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
PlatinumPlus
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit
If you've had Part B for longer than 12 months, you can
get an annual wellness visit to develop or update a
personalized prevention plan based on your current health
and risk factors. This is covered in full once every 12
months. Your first annual wellness
visit can't take place within 12 months of your "Welcome
to Medicare" preventive visit. However, you don't need to
have had a "Welcome to Medicare" visit to be covered for
annual wellness visits after you've had Part B for 12
months.
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Medicare Platinum
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit
If you've had Part B for longer than 12 months, you can
get an annual wellness visit to develop or update a
personalized prevention plan based on your current health
and risk factors. This is covered in full once every 12
months. Your first annual wellness
visit can't take place within 12 months of your "Welcome
to Medicare" preventive visit. However, you don't need to
have had a "Welcome to Medicare" visit to be covered for
annual wellness visits after you've had Part B for 12
months.
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
Medicare Advantage
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
BronzePlus HSA
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
SilverPrime
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
Annual Wellness Visit (Well-Baby, Well-Child, Well-
Adult) •Well-Baby and Well-Child Care - one (1) visit
per calendar year, which consists of routine physical
examinations including vision and hearing screenings,
developmental assessment, anticipatory guidance, and
laboratory tests ordered at the time of the visit.
•Well-Adult - one (1) visit per calendar year, regardless of
whether or not 365 days have passed since the previous
physical examination visit. Vision screenings do not
include refractions.
•Well-Woman Examinations which consist of the
following HRSA requirements for Women: Behavioral
Assessments, Breastfeeding support and counseling (This
service is included in the Primary Care or OB/GYN Office
Visits): Contraceptive methods counseling and follow-up
Care, Domestic violence screening, Annual HIV counseling,
Sexually transmitted infections counseling, Screening for
urinary incontinence **For the purpose of promoting
good health and early detection of disease. Preventive
services are not subject to Cost-Sharing, Copayments or
Coinsurance when performed by a Participating Provider
and provided in accordance with the comprehensive
guidelines supported by the Health Resources and
Services Administration (HRSA), or if the items or services
have an "A" or "B" rating from the United States
Preventive Task Force (USPSTF), or if the immunizations
are recommended by the Advisory Committee on
Immunization Practices (ACIP).
99201-99215,
99241-99245,
99341-99350,
99381-99387,
99497, 99498,
G0402-G0405,
G0438, G0439, G0468,
G0513, G0514, S0610,
S0612, S0613, S9443
GoldPrime
G0438 - once per lifetime G0439 - once per lifetime Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services; Use
appropriate procedure code/s based on patient's age
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
-
2 PREVENTIVE CARE
BRCA risk assessment and genetic counseling/testing
The USPSTF recommends that primary care clinicians
assess women with a personal or family history of breast,
ovarian, tubal, or peritoneal cancer or who have an
ancestry associated with breast cancer susceptibility 1
and 2 (BRCA1/2) gene mutations with an appropriate brief
familial risk assessment tool. Women with a positive
result on the risk assessment tool should receive genetic
counseling and, if indicated after counseling, genetic
testing. **For the
purpose of promoting good health and early detection of
disease. Preventive services are not subject to Cost-
Sharing, Copayments or Coinsurance when performed by
a Participating Provider and provided in accordance with
the comprehensive guidelines supported by the Health
Resources and Services Administration (HRSA), or if the
items or services have an "A" or "B" rating from the
United States Preventive Task Force (USPSTF), or if the
immunizations are recommended by the Advisory
Committee on Immunization Practices (ACIP).
BRCA Lab Test: 81162 -
81167, 81212, 81215 -
81217 Other procedures:
99201 - 99215, 99385 -
99397, 96040, G0463,
S0265
Medicaid
Covered for age 18 and older; Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services
YES for BRCA Lab Test
81162 - 81167, 81212,
81215 - 81217
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE CARE
BRCA risk assessment and genetic counseling/testing
The USPSTF recommends that primary care clinicians
assess women with a personal or family history of breast,
ovarian, tubal, or peritoneal cancer or who have an
ancestry associated with breast cancer susceptibility 1
and 2 (BRCA1/2) gene mutations with an appropriate brief
familial risk assessment tool. Women with a positive
result on the risk assessment tool should receive genetic
counseling and, if indicated after counseling, genetic
testing. **For the
purpose of promoting good health and early detection of
disease. Preventive services are not subject to Cost-
Sharing, Copayments or Coinsurance when performed by
a Participating Provider and provided in accordance with
the comprehensive guidelines supported by the Health
Resources and Services Administration (HRSA), or if the
items or services have an "A" or "B" rating from the
United States Preventive Task Force (USPSTF), or if the
immunizations are recommended by the Advisory
Committee on Immunization Practices (ACIP).
BRCA Lab Test: 81162 -
81167, 81212, 81215 -
81217 Other procedures:
99201 - 99215, 99385 -
99397, 96040, G0463,
S0265
Essential Plan 1
Non-Aliessa
Covered for age 18 and older; Use
appropriate ICD10 code/s for benefits to apply under
Preventive Services
YES for BRCA Lab Test
81162 - 81167, 81212,
81215 - 81217
Y-ALL OUT OF NETWORK Y-ALL OUT OF NETWORK IN NETWORK
2 PREVENTIVE
