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Effective for plan years beginning on or after August 1, 2012 SUBJECT TO CHANGE BASED ON FEDERAL REGULATIONS City Of Laramie Preventive/Wellness Benefits These benefits meet the criteria outlined in the Patient Protection and Affordable Care Act (PPACA) for wellness and preventive benefits including the Women’s Preventive requirement. In addition, these benefits meet the definition of comprehensive adult wellness benefits in the Wyoming Health Insurance Code. Benefits, OTHER than those outlined below, will not be covered as a preventive or wellness benefit. When services are provided by Participating providers, benefits will be provided at 100% of the Allowable Charges for Covered Services without regard to any Deductible or Coinsurance that might otherwise apply. When services are provided by non-participating providers, benefits will not be provided for Preventive Care. The following services are covered preventive services: • Well Child Care to the Participant’s 6th Birthday o Birth through 12 months – 7 visits o 13 months through 35 months – 4 visits o 36 months through 72 months – 1 visit per calendar year o Immunizations as recommended by the CDC o Congenital hypothyroidism screening under age 1 o Hearing loss screening up to 1 month of age o Phenylketonuria (PKU) screening – once per lifetime ages 0 – 1 years old o Sickle cell disease screening – up to age 1 o Iron deficiency anemia prevention for children at risk 6 to 12 months o Hematocrit or Hemoglobin through age 1 o Lead Screening through age 6 o Developmental and Autism Screening through age 2 • Birth Through Age 21 o Sensory Screening Vision – 1 per calendar year o Sensory Screening Hearing – 1 per calendar year (in addition to screening listed above) through age 21 o Tuberculin Test ---PAGE BREAK--- Effective for plan years beginning on or after August 1, 2012 SUBJECT TO CHANGE BASED ON FEDERAL REGULATIONS • Participants Age 6 and Older: o Routine physical examination (office visit) – Males 1 per calendar year Well-woman preventive care visits as medically appropriate o Adult aortic aneurysm screening for male participants age 65-75 – lifetime maximum of 1 screening o Alcohol misuse screening and behavioral counseling intervention – 1 visit per calendar year o Asymtomatic bacteriuria screening – pregnant women only o Hepatitis B virus screening – pregnant women only o Rh incompatibility screening – pregnant women only o Osteoporosis screening once every 2 calendar years – females age 65 and older unless at risk, then 60 and older o Iron deficiency anemia screening – pregnant women only o Sexually transmitted disease (STD) screening: § Chlamydial infection screening – women only § Gonorrhea infection screening – women only § Syphilis infection screening – pregnant women, and men and women at risk o Counseling for sexually transmitted infections o Screening for diabetes in pregnant women 24-48 weeks gestation o HPV Testing – 30 yrs of age every 3 years o Screening and Counseling for interpersonal & domestic violence o Lactation support & counseling services – 2 visits per pregnancy o Breast Pump – 1 pump per pregnancy (manual or electric pump from a Network Home Medical Equipment provider only). Prior approval is required for hospital grade pumps. o Counseling and screening for HIV o Contraceptive methods & management (Medical) – Female sterilizations; IUD inserted or removed & inserted on the same day; Injections used to prevent conception o Diagnostic screening procedure for HIV testing for at risk participants and pregnant women o Type 2 diabetes mellitus screening o Immunizations as recommended by the CDC o Colorectal cancer screening for members age 50 through 75: § Fecal occult blood test – 1 per calendar year § Colonoscopy (including related services) – 1 every 10 years OR § Sigmoidoscopy (including related services) – 1 every 5 years o Cervical cancer screening and related office visit – 1 per calendar year o PSA test – 1 per calendar year for subscriber and spouse only o Mammogram screening – 1 per calendar year for subscriber and spouse only (only covered 1 per calendar year for subscriber and spouse for ages 40+ under PPACA) o Tobacco cessation counseling – 8 visits per calendar year o Lipid disorders screening every 5 calendar years ---PAGE BREAK--- Effective for plan years beginning on or after August 1, 2012 SUBJECT TO CHANGE BASED ON FEDERAL REGULATIONS • Prescription Drugs* - must be filled as a prescription and submitted through the prescriptions drug card program o Aspirin – limited to 81 mg only § Ages 45 – 79 for males § Ages 55 – 79 for females o Folic acid (non prenatal) – limited to 0.4 – 0.8 mg only § Women only o Oral fluoride – over the counter or prescription strength § Children age 6 months – 6 years when sufficient fluoride is lacking in available drinking water o Iron supplements § Children age 6 – 12 months and at risk for anemia o Tobacco cessation – up to a 180 day supply § Non-nicotine replacement therapy (pills) § Over the counter nicotine replacement therapy (lozenges, patch and gum) § Prescription nicotine replacement therapy (nasal spray and inhalers) o Contraceptives used to prevent conception – Tier 1 & 2 paid at 100%; Tier 3 subject to co-pay and coinsurance. Over-the-counter is not covered. § Oral § Patches § Vaginal Rings *Brand Drugs – If the participant chooses a brand drug when a generic drug is available, the participant must pay the difference in cost between the brand and the generic drug.