Preventive Services Form

GRP20474-2605 Preventive Service The following preventive services and immunizations do not apply to all health plans administered or insured by Blue Cross and Blue Shield of Alabama. Some or all of the contraceptive methods or prescription drugs listed may not be covered under the plan because of the employer’s religious beliefs.
To find out if contraceptive methods and prescription drugs are excluded, please contact Customer Service for additional information. If the preventive services section of your plan’s benefit booklet refers you to AlabamaBlue.com, the preventive services and immunizations listed below will be covered by your plan. However, your group may decide to delay the effective date for coverage until your group’s plan year for any new preventive services and immunizations recently added to this list. If your plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from your office or other facility visit. In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of your benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for your visit is not routine preventive services and/or routine immunizations. Please ask the provider to contact your Health Plan to verify the procedure and diagnosis codes that are covered under these preventive services. If you have any questions about your plan’s benefits, you may also call our Customer Service Department at the number on the back of your ID card. Contact your group benefit administrator for information regarding the effective date of new preventive services and immunization recently added to the list below Preventive Services For Adults Frequency/Limitations Abdominal Aortic Aneurysm Screening Age 65-75 one screening per lifetime (men only with any history of smoking) Alcohol Misuse Screening and Behavioral Counseling Interventions
One per calendar year Ambulatory Blood Pressure Monitoring Once per lifetime to confirm the diagnosis of hypertension Blood Pressure Screening Age 18 and older, one per calendar year (included as part of an office visit) Cholesterol Screening Men age 35 and older (20-35 at risk for CAD), Women age 45 and older
(20-45 at risk for CAD) every 5 years Colorectal Cancer Screening (Follow-up colonoscopy after a positive stool-based test considered under the preventive benefit when billed in accordance with the preventive guidelines.) Age 45-75 • Fecal occult blood testing One per calendar year • CT Colonography (Visual Colonoscopy) Every 5 years • Sigmoidoscopy Every 3 years • Colonoscopy (including bowel prep medications) Every 10 years • Barium Enema Every 5 years • Pre-Screening Consultation Every 10 years • FIT-DNA (e.g., Cologuard, Cologuard Plus) Every 3 years Depression, Anxiety, and Suicide Risk Screening Age 8 and older, three per calendar year Diabetes Screening Age 19 and older, every 3 years Diet Counseling (Adults with high risk for chronic disease) Age 18 and older, three hours each calendar year Fall Prevention Screening Age 65 and older. Exercise, physical therapy and vitamin D supplementation Hepatitis B Screening Age 11 and older, one per calendar year Hepatitis C Screening Once per lifetime; Once per year for individuals at high risk for infection HIV Screening (At Risk and All Pregnant Women) Age 10 and older HIV Infection Prevention: Pre-exposure Prophylaxis (PrEP) (Antiretroviral medication to be considered under the pharmacy plan when ordered by a physician) The following services for baseline/ follow-up testing and monitoring are included per the CDC PrEP guidelines (ages 10 and older): • Kidney function testing (creatinine) • Pregnancy testing (when appropriate) • Hepatitis B and C testing • Adherence counseling • HIV Testing • Associated office visits • STI screening and counseling Lung Cancer Screening Age 50-80, one per calendar year Prostate Screening Men age 40 and older, one per calendar year Preventive Office Visit One per calendar year

GRP20474-2605 Sexually Transmitted Infection Prevention Counseling Age 10 and older, one per calendar year Tobacco Use Counseling Age 6 and older, 8 per calendar year Tuberculosis Infection Screening Age 19 and older (adults at risk), one per calendar year Preventive Services for Women (Including Pregnant Women) Frequency/Limitations Bacteriuria (Pregnant Women) With pregnancy BRCA Counseling about genetic testing for women at higher risk Once in a lifetime Breast Cancer Chemoprevention Counseling Once in a lifetime Breast Cancer Screening Age 35-39 one baseline screening mammogram, age 40 and older one screening mammogram per calendar year

• Includes additional imaging (e.g., MRI, ultrasound, mammography) and pathology
  evaluation, if indicated to complete the screening process (Effective 1/1/26). Breastfeeding Support • Behavioral Interventions Twice per calendar year • Counseling and Support Age 10 and older, five per year in conjunction with a birth • Supplies - Pumps and Accessories Age 10 and older; one electric breast pump allowed per pregnancy Cervical Cancer Screening (Pap Smear) One per calendar year Chlamydia Screening Age 15 and older, one per calendar year Contraceptive Methods and Counseling • Counseling Age 10 and older, one annually • Sterilization Age 10 and older, one procedure per lifetime • Confirmatory Test Two per lifetime • Contraceptive - Mobile Application Age 10 and older, one 12-month subscription per calendar year. *Coverage includes member reimbursement for the cost of FDA-approved, cleared, or granted mobile device applications for use as contraception consistent with the FDA- approved, cleared, or granted indication • Contraceptive - Medical Age 10 and older Gonorrhea Screening Age 11 and older, twice per calendar year Healthy Weight Gain in Pregnancy Counseling Age 10 and older, three hours per calendar year Hepatitis B Screening One per calendar year for pregnant women HIV Screening (At Risk and All Pregnant Women) Age 10 and older HIV Counseling Age 10 and older, one per calendar year Human Papillomavirus (HPV) Screening Age 30 and older, every 3 years Iron Deficiency Anemia Screening One per calendar year for pregnant women Osteoporosis Screening Age 65 and older, 65 and younger if at risk once every 2 years Patient Navigation Services for Breast and Cervical Cancer Screening
  (Effective 1/1/26) Included in preventive office visit Preconception Visit Age 10 and older, one visit per calendar year Prenatal Care Age 10 and older, up to six visits per calendar year depending on diagnosis Preeclampsia Screening Age 10 and older (included in prenatal office visit) Perinatal Depression Preventive Interventions Age 10 and older, three hours per calendar year Prenatal Conference (Pediatrician only) With pregnancy Preventing Obesity in Midlife Women Counseling Age 40-60 year, one hour per year Rh Incompatibility Screening (All Pregnant Women) Twice per calendar year Screening and Counseling for Interpersonal and Domestic Violence
  Age 10 and older, one per calendar year Screening for Diabetes during Pregnancy Age 10 and older, two per calendar year Screening for Diabetes after Pregnancy Age 10 and older, two per calendar year Sexually Transmitted Infection (STI) Prevention Counseling Age 10 and older, one per calendar year Syphilis Screening (At Risk and All Pregnant Women) No frequency limit Tobacco Use Counseling (Pregnant Women) Age 10 and older, 8 per calendar year

GRP20474-2605 Immunizations
(Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, anddosage. Refer to the CDC website to view the schedules: cdc.gov/vaccines/schedules/index.html) COVID-19 vaccine Diphtheria Toxoid Diphtheria, Tetanus (DT) Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Haemophilus Influenza Type B, and Poliovirus Vaccine, Inactivated (DTaP-Hib-IPV) Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine, Hepatitis B, and Poliovirus Vaccine, Inactivated (DTaP-HepB-IPV) Diphtheria, Tetanus, Acellular Pertussis (DTap) Diphtheria, Tetanus, Acellular Pertussis and Haemophilus Influenza B Vaccine (DTaP-Hib) Diphtheria, Tetanus Toxoids, Acellular Pertussis Vaccine and Poliovirus Vaccine, Inactivated (Dtap-IPV) Well Women Visit Age 10 and older, up to two visits per calendar year depending on diagnosis Preventive Services for Children Frequency/Limitations Alcohol and Drug Use Assessments (Adolescents) Age 11-21, one per calendar year Behavior Counseling to Prevent Skin Cancer Age 6 months-24 years (included in preventive office visit) Cervical Cancer Screening (Pap Smear) One per calendar year Congenital Hypothyroidism (Newborns) Age 2-4 days Depression, Anxiety, and Suicide Risk Screening Age 8 and older, three per calendar year Dental Caries Prevention (<age 5) Age birth - 5 years, 4 per calendar year Dental Caries Prevention (Preschool Children) Included in preventive office visit Developmental Screening (<age 3) Age birth - 30 months, 5 screenings Developmental Surveillance Included as part of an office visit Dyslipidemia Age 2-10, one every 2 years; Age 11-17, one per calendar year; Age 18-21, once during age range Gonorrhea Prevention (Eye Meds for Newborns) At delivery; included in standard inpatient newborn care Hearing Screening (Newborns) Age birth - 31 days, once in age range Hearing Screening Age 2 months - 10 years, 8 tests during age range; Age 11-21, 3 tests during age range Hematocrit or Hemoglobin Screening Age 4 months - 10 years, 3 services during age range; Age 11-21, one per calendar year Hemoglobinopathies (sickle cell screening for newborns) Age birth - 31 days Hepatitis B Screening Age 11 and older, one per calendar year High Body Mass Index in Children and Adolescents Interventions (Effective 7/1/25) Age 6-17 years, 26 services per year HIV Screening (Adolescents at High Risk) Age 10 and older Lead Screening Age 6 months - 6 years, 3 services during age range Maternal Depression Screening Age birth - 6 months, 4 services during age range Metabolic Hemoglobin Screening (Newborns) Age birth - 2 months, once in age range Oral Health Risk Assessment Age 6 months - 6 years, 3 services during age range Routine Newborn Care (In Hospital) Included in standard inpatient newborn care Phenylketonuria (PKU for Newborns) Age 2-14 days, 2 services during age range Psychosocial/Behavioral Assessment Age Newborn - 21 years, 31 services during age range Preventive Office Visit 9 visits first two years of life; Age 2, two visits per birth year; Age 3-6, one each year (based on birth year); Age 7 and older, one visit per calendar year
Sexually Transmitted Infections Counseling Age 10 and older, one per calendar year Sexually Transmitted Infections Screening Age 11-21, No frequency limit Sudden Cardiac Arrest and Sudden Cardiac Death Screening Age 11-21 years, included in preventive office visits Tuberculin Testing Age 1 month - 21 years, 6 services during age range Vision Screening (Visual Acuity) Birth - 10 years, 8 services in age range. Age 11-21, 4 services in age range

GRP20474-2605 An Independent Licensee of the Blue Cross and Blue Shield of Association Please note the services listed are as of January 2026, and are subject to change at any time. Please visit AlabamaBlue.com/PreventiveServices to view the latest list of our standard preventive services. Pharmacy Benefits (To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy) Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality Women age 10 and older Contraceptives Women only; generic only Fluoride Ages 6-16 years Folic Acid Women only Breast Cancer Preventive Drugs Women age 35 and older Tobacco Cessation Products Two 90-day regimens of an FDA-approved tobacco cessation medications, (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization Iron Supplements Ages 6-12 months Statin Medications Ages 40-75 years with one or more cardiovascular risk factors and calculated
10-year risk of a cardiovascular event of 10% or greater. Prevention of HIV Infection: Pre-exposure Prophylaxis (PrEP) (Antiretroviral medication to be considered under the pharmacy plan when ordered by a physician.) Tthe following services for baseline/ follow-up testing and monitoring are included per the CDC PrEP guidelines (ages 10 and older): • Kidney function testing (creatinine) • Pregnancy testing (when appropriate) • Hepatitis B and C testing • Adherence counseling • HIV Testing • Associated office visits • STI screening and counseling Immunizations
Haemophilus Influenza B Vaccine (HIB) Hepatitis A Hepatitis A and B Hepatitis B and Haemophilus Influenza B Vaccine - Active Immunization (HepB - Hib) Hepatitis B Vaccine - Active Immunizations (HepB) Human Papilloma Virus (HPV) Influenza Virus Vaccine Measles Virus Vaccine - Live Measles, Mumps and Rubella Vaccine (MMR) Measles, Mumps, Rubella, and Varicella Vaccine (MMRV) Meningococcal Conjugate Vaccine MenABCWY (pentavalent meningococcal) vaccine Meningococcal Serogroup B Vaccine Mpox Vaccine (formerly known as monkeypox) Mumps Virus Vaccine - Live Pneumococcal Conjugate (PCV) /Pneumococcal Polysaccharide Vaccine Poliomyelitis Vaccine (IPV) Respiratory Syncytial Virus (RSV) vaccine/monoclonal antibody Rotavirus Vaccine Rubella Virus Vaccine Tetanus Toxoid Tetanus, Diphtheria, Acellular Pertussis (Tdap) Varicella (Chicken Pox) Vaccine Zoster (Shingles) Vaccine