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Preventive Services Guidelines
for Enrollees in HSA Plans
Effective January 1, 2008
The following preventive services will be covered in full (plan pays 100%) when rendered by in-network providers and billed as routine preventive care. Age and frequency restrictions apply. Diagnostic tests performed to investigate existing symptoms or to monitor on-going conditions are not covered as preventive care but are covered subject to your deductible and coinsurance. A covered preventive service that is billed with multiple diagnoses which includes both a covered preventive and diagnostic billing code will be paid at 100% as preventive care. If you are billed for a covered preventive service with multiple diagnoses, you may need to contact your health plan to request your preventive claim be processed as preventive. Out-of-network preventive services are subject to the deductible then covered at a 40%
Annual Physicals
One routine physical exam covered per enrollee per year. The following preventive
screenings are covered as part of your physical based on age and physician
recommendation: height & weight, standard blood work (blood count, cholesterol, blood
sugar …), urinalysis, blood pressure, chest x-rays, stress test, EKG, and osteoporosis
screening (bone density). Osteoporosis screenings (bone density) are only covered for
members age 65 and older).
Both the office visit as well as the lab service are covered in full when billed as preventive.
Well Baby Care
Routine well baby services covered for first 24 months of life.
Flu Shot
One per calendar year with no age restriction – must be administered in the physician
office.

Prostate-Specific Antigen (PSA) Screening
One PSA screening each year beginning at age 40.
PAP Smear Services
One routine Papanicolaou (PAP) smear per female enrollee per year.
Both the office visit as well as the lab service are covered in full when billed as preventive.
Proctoscopic Examinations
Proctoscopic examinations without biopsy are covered benefits once every three (3)
calendar years after age 40 is attained. Proctoscopic examinations with biopsy are
covered once per year.


J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf Mammography Screening
One baseline mammogram between the ages of 35 and 39 One mammogram every 1 to 2 years between ages 40 through 49 depending on risk One mammogram each year beginning at age 50
Early Detection Screening
Early Detection Test
Begin at Age Frequency
*Eligible for one of the three tests beginning at age 50

Immunization Program
Immunizations
Number of Doses - Age
4 – Under age 19 3 – Age 19 and older 4 IPV – series ending at 4-6 years of age 1 - Age 7 and above 1 – Td Booster every 10 years for adults Note: Additional diagnostic tests may be covered subject to your deductible and coinsurance. This summary of preventive services provides guidelines on the 100% covered benefits as part of your HSA plan. J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf Tips to Use at Your Doctor’s Office
Disease prevention and early detection are important to living a healthy life. The better your health, the less your health care costs. Preventive services through the HSA Plans (Definity Health + HSA and the CIGNA / HAP Choice + HSA) include wellness examinations, labs, radiology and routine screenings. Preventive care is covered in full (paid at 100%) when care is received in-network and follows the Company benefit preventive guidelines. Exclusions: Preventive care does not include maintenance care for diagnosed medical conditions or services performed to diagnose a probable medical condition when symptoms are presented. Example:
Your dependent child goes in for a routine physical examination, blood work, and immunizations. During the examination, results indicate that your child’s glands are swollen and his or her white blood cell count is elevated. Additional blood work is ordered to diagnose the medical condition. The claim will be paid at 100% for the initial exam, simple blood work, and immunizations. However, you will have to pay a deductible and/or coinsurance for the rest of the cost of the additional blood work related to the swollen glands and the elevated white blood cell count. The additional blood work is diagnostic as your child has symptoms and the additional tests/medical services are not considered preventive. Preventive services vs. diagnostic services
Your physician or other health care provider should code routine annual physicals as preventive and should not use diagnostic procedure codes. If a medical condition is diagnosed or considered probable during the preventive physical exam, any supplemental tests will be coded as diagnostic services. You should ask your physician to bill these separately from the preventive physical exam to ensure that the exam is paid as preventive. Example:
You go in for a routine physical examination and routine blood work. During the examination, you advise your physician that you have been having chest pain and shortness of breath. The physician then orders a chest x-ray. The exam and routine blood work will be paid at 100%. However, the chest x-ray will be billed with a medical diagnosis based on your symptoms. The chest x-ray is a covered service but it is not preventive because you have symptoms, and you will have to pay a deductible and coinsurance. What to watch for when your claim is paid
If any of your preventive care screenings or tests (e.g., pap smear) come back as abnormal, please review your claim payments carefully to ensure that the cost of your office visit has been coded and paid as preventive care. J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf Helpful Tip
Your physician or other health care provider should code preventive care as routine - even if the initial test result is abnormal. If your claim is not paid as preventive care, call your provider and ask them to rebill your claim with a preventive billing code. A covered preventive service that is billed with multiple diagnoses which include both a covered preventive and diagnostic billing code will be paid at 100% as preventive care. If you are billed for a covered preventive service with multiple diagnoses, you may need to contact your health plan to request your preventive claim be processed as preventive. Any follow-up office visits or supplemental testing as the result of a diagnosed or probable medical condition are not considered preventive care and will be subject to the deductible and co-insurance. On occasion, preventive laboratory charges associated with your preventive care office visit may be processed before the office visit charge is submitted by your health care provider. This may result in denial of the preventive laboratory service. When this happens, call the number on the back of your medical ID card for assistance. Common Routine Preventive Care Billing Codes
Make sure your physician uses preventive care routine codes on the claim such as: Gynecological exam, including pap smear - V Code V72.3 Radiological exam, including routine chest X-ray - V Code V72.5 J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf 2008 HSA Plan Preventive Drug List
Generic drugs in the following categories will be covered at 100% by the HSA Plan and will not count toward the member’s deductible or out-of-pocket maximum. Please note that as new generic drugs within these categories become available, they will be added by the Pharmacy Benefit Manager (PBM). Members can always check their PBM’s customer service or member website if they want to confirm availability of a specific generic drug or have questions. Coverage of these drugs at 100% is only for the condition/indication in these categories. Generic Asthma Drugs
Generic Name
Common Label Name
Ventolin, Proventil,Ventolin HFA, ProAir HFA, and Proventil HFA Slo-bid, Theo-Dur,Uniphyl, Elixophyllin, Aerolate

Brand Name Asthma Inhalers
Recently, the Federal Drug Administration (FDA) ruled that manufacturers of one of the
generic Asthma medications, albuterol sulfate, must phase out albuterol inhalers
containing chlorofluorocarbon (CFC) by December 31, 2008. As a result, new inhalers
have entered the market that replace CFC with a new ingredient, hydrofluoroalkane (HFA).
HFA inhalers contain the same medicine and provide the same relief as the CFC inhaler.
Currently, the HFA inhalers are available as brand only.
Because a generic version of the HFA inhalers is currently not available, Chrysler has
decided to cover at 100% the brand HFA inhalers at this time. Again, this means that
there is no co-pay and the cost of these medications does not count toward your
deductible or out-of-pocket maximum. The brand name HFA inhalers currently available
are Ventolin® HFA, ProAir® HFA, and Proventil® HFA.
J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf Generic Diabetes Drugs

Generic Name
Common Label Name
Generic Blood Thinners Drugs
Generic Name
Common Label Name
Generic Cholesterol Drugs
Generic Name
Common Label Name
Generic Antihypertensive Drugs
Generic Name
Common Label Name
amiloride besylate/hydrochlorothiazide Moduretic amiloride hcl J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf J:/2008 Annual Enrollment/2008 HSA Preventive Care.pdf

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