Common use of Preventive Care Services Clause in Contracts

Preventive Care Services. Coverage is provided for preventive care Services, including: 1. Evidence-based items or Services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, except that the recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography and prevention issued during or around November 2009 are not considered to be current. Visit: xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx; 2. Immunizations for routine use in children, adolescents and adults that have a recommendation in effect from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. A recommendation from the Advisory Committee on Immunization Practices of the CDC is considered to be: in effect after it has been adopted by the director of the CDC and for routine use if it is listed on the immunization schedules of the CDC. Visit: xxx.xxx.xxx/xxxxxxxx/xxxx/XXXX; 3. With respect to infants, children and adolescents: Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 4. With respect to women (to the extent not described in paragraph “a” above), evidence- informed preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 5. A voluntary Health Risk Assessment that can be completed by Members annually. Written feedback provided to Members will include recommendations for addressing identified risks; 6. All United States Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity; 7. Routine prenatal care; 8. BRCA counseling and genetic testing. Any follow up Medically Necessary treatment is covered at the applicable Cost Share based upon type and place of service; and 9. Medically Necessary digital tomosynthesis, commonly referred to as three-dimensional “3_D”

Preventive Care Services. Coverage is provided for preventive care Services, including: 1. Evidence-based items or Services that have in effect a rating of "A" or "B" in The coverage described below shall be consistent with the current recommendations requirements of the United States Affordable Care Act (ACA). Preventive Care Services are covered for children and adults, as directed by your Physician, based on the guidelines from the following resources: • U.S. Preventive Services Task Force, except that the Force Grade A & B recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography and prevention issued during or around November 2009 are not considered to be current. Visit: xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx; 2. Immunizations for routine use in children, adolescents and adults that have a recommendation in effect from the (xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx/xxxxxx/xxxxxxxxxx.xxx) • The Advisory Committee on Immunization Practices of (ACIP) that have been adopted by the Centers Center for Disease Control and Prevention (CDCxxx.xxx.xxx/xxxxxxxx/xxxx/XXXX/) with respect to the individual involved. A recommendation from the Advisory Committee on Immunization Practices of the CDC is considered to be: in effect after it has been adopted by the director of the CDC and • Guidelines for routine use if it is listed on the immunization schedules of the CDC. Visit: xxx.xxx.xxx/xxxxxxxx/xxxx/XXXX; 3. With respect to infants, children children, adolescents and adolescents: Evidence-informed women’s preventive health care and screenings provided for in the comprehensive guidelines as supported by the Health Resources and Services AdministrationAdministration (HRSA) (xxx.xxxx.xxx/xxxxxxxxxxxxxxxx/) Your Physician will evaluate your health status (including, but not limited to, your risk factors, family history, gender and/or age) to determine the appropriate Preventive Care Services and frequency. To see The list of Preventive Care Services are available through xxx.xxxxxxxxxx.xxx/xxxx/xxxxxxxxxx/0000/00/xxxxxxxxxx- services-list.html. Examples of Preventive Care Services include, but are not limited to: • Periodic health evaluations • Preventive vision and hearing screening • Blood pressure, diabetes, and cholesterol tests • USPSTF and HRSA recommended cancer screenings, including FDA-approved human papillomavirus (HPV) screening test, screening and diagnosis of prostate cancer (including prostate-specific antigen testing and digital rectal examinations), screening for breast, cervical and colorectal cancer, human im- munodeficiency virus (HIV) screening, mammograms and colonoscopies • Developmental screenings to diagnose and assess potential developmental delays • Counseling on such topics as quitting smoking, lactation, losing weight, eating healthfully, treating depression, prevention of sexually transmitted diseases, and reducing alcohol use • Routine immunizations against diseases such as measles, polio, or meningitis • Flu and pneumonia shots • Vaccination for acquired immune deficiency disorder (AIDS) that is approved for marketing by the current guidelinesFDA and that is recommended by the United States Public Health Service • Counseling, visit: xxxx://xxxx.xxxx.xxxscreening, and immunizations to ensure healthy pregnancies • Regular well-baby and well-child visits • Well-woman visits Preventive Care Services for women also include screening for gestational diabetes; 4sexually-transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contra- ception methods for women and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling. With respect One breast pump and the necessary supplies to women operate it (as prescribed by your Physician) will be covered for each pregnancy at no cost to the extent not described in paragraph “a” above)Member. This includes one retail-grade breast pump (either a manual pump or a standard electric pump) as prescribed by Your Physician. We will determine the type of equip- ment, evidence- informed preventive care whether to rent or purchase the equipment and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administrationvendor who provides it. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 5. A voluntary Health Risk Assessment that Breast pumps can be completed obtained by Members annually. Written feedback provided to Members will include recommendations for addressing identified risks; 6. All United States Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity; 7. Routine prenatal care; 8. BRCA counseling and genetic testing. Any follow up Medically Necessary treatment is covered calling the Customer Contact Center at the applicable Cost Share based upon type phone number on your Health Net ID card. Preventive Care Services are covered as shown in the "Schedule of Benefits and place Copayments – SELECT 1" and "Schedule of service; Benefits and 9Copayments – SELECT 2 and SELECT 3" sections. Surgical Services Services by a surgeon, assistant surgeon, anesthetist or anesthesiologist are covered. Non-emergency services provided by an assistant surgeon in an Out of Network (OON) facility are pre-authorized by Health Net and covered only when determined by Health Net to be Medically Necessary digital tomosynthesisNecessary. Health Net uses available guidelines of Medicare and its contractors, commonly referred other governmental regulatory bodies and nationally recognized medical societies and organizations to assist in its determination as threeto which services and procedures are eligible for reimbursement. Health Net uses Medicare guidelines to determine the circumstances under which claims for assistant surgeon services and co-dimensional “3_D”surgeon and team surgeon services will be eligible for reimbursement, in accordance with Health Net’s normal claims filing requirements. When adjudicating claims for Covered Services for the postoperative global period for surgical procedures, Health Net applies Medicare’s global surgery periods to the American Medical Association defined Surgical

Preventive Care Services. Coverage is provided for preventive care Services, including: 1. Evidence-based items or Services that have in effect a rating of "A" or "B" in The coverage described below shall be consistent with the current recommendations requirements of the United States Affordable Care Act (ACA). Preventive Care Services are covered for children and adults, as directed by your Physician, based on the guidelines from the following resources: U.S. Preventive Services Task Force, except that the Force Grade A & B recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography and prevention issued during or around November 2009 are not considered to be current. Visit: xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx; 2. Immunizations for routine use in children, adolescents and adults that have a recommendation in effect from the (xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx/xxxxxx/xxxxxxxxxx.xxx) The Advisory Committee on Immunization Practices of (ACIP) that have been adopted by the Centers Center for Disease Control and Prevention (CDCxxx.xxx.xxx/xxxxxxxx/xxxx/XXXX/) with respect to the individual involved. A recommendation from the Advisory Committee on Immunization Practices of the CDC is considered to be: in effect after it has been adopted by the director of the CDC Page 46 Covered Services and Supplies Guidelines for routine use if it is listed on the immunization schedules of the CDC. Visit: xxx.xxx.xxx/xxxxxxxx/xxxx/XXXX; 3. With respect to infants, children children, adolescents and adolescents: Evidence-informed women’s preventive health care and screenings provided for in the comprehensive guidelines as supported by the Health Resources and Services AdministrationAdministration (HRSA) (xxx.xxxx.xxx/xxxxxxxxxxxxxxxx/) Your Physician will evaluate your health status (including, but not limited to, your risk factors, family history, gender and/or age) to determine the appropriate Preventive Care Services and frequency. To see The list of Preventive Care Services are available through xxx.xxxxxxxxxx.xxx/xxxx/xxxxxxxxxx/0000/00/xxxxxxxxxx- services-list.html. Examples of Preventive Care Services include, but are not limited to: Periodic health evaluations Preventive vision and hearing screening Blood pressure, diabetes, and cholesterol tests Many cancer screenings, including FDA-approved human papillomavirus (HPV) screening test, mammo- grams and colonoscopies Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use Routine immunizations against diseases such as measles, polio, or meningitis Flu and pneumonia shots Counseling, screening, and immunizations to ensure healthy pregnancies Regular well-baby and well-child visits Well-woman visits Preventive Care Services for women also include screening for gestational diabetes; sexually-transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contra- ception methods for women and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling. One breast pump and the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 4. With respect necessary supplies to women operate it (as prescribed by your Physician) will be covered for each pregnancy at no cost to the extent not described in paragraph “a” above)Member. We will determine the type of equipment, evidence- informed preventive care whether to rent or purchase the equipment and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administrationvendor who provides it. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 5. A voluntary Health Risk Assessment that Breast pumps can be completed obtained by Members annually. Written feedback provided to Members will include recommendations for addressing identified risks; 6. All United States Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity; 7. Routine prenatal care; 8. BRCA counseling and genetic testing. Any follow up Medically Necessary treatment is covered calling the Customer Contact Center at the applicable Cost Share based upon type phone number on your Health Net ID card. Preventive Care Services are covered as shown in the "Schedule of Benefits and place Copayments – SELECT 1" and "Schedule of service; Benefits and 9Copayments – SELECT 2 and SELECT 3" sections. Surgical Services Services by a surgeon, assistant surgeon, anesthetist or anesthesiologist are covered. Non-emergency services provided by an assistant surgeon in an Out of Network (OON) facility are pre-authorized by Health Net and covered only when determined by Health Net to be Medically Necessary digital tomosynthesisNecessary. Health Net uses available guidelines of Medicare and its contractors, commonly referred other governmental regulatory bodies and nationally recognized medical societies and organizations to assist in its determination as threeto which services and procedures are eligible for reimbursement. Health Net uses Medicare guidelines to determine the circumstances under which claims for assistant surgeon services and co-dimensional “3_D”surgeon and team surgeon services will be eligible for reimbursement, in accordance with Health Net’s normal claims filing requirements. When adjudicating claims for Covered Services for the postoperative global period for surgical procedures, Health Net applies Medicare’s global surgery periods to the American Medical Association defined Surgical Package. The Surgical Package includes typical postoperative care. These criteria include consideration of the time period for recovery following surgery and the need for any subsequent services or procedures which are part of routine postoperative care. When multiple procedures are performed at the same time, Covered Expenses include the Contracted Rate or Maximum Allowable Amount (as applicable) for the first (or major) procedure and one-half the Contracted Rate or Maximum Allowable Amount for each additional procedure. Health Net uses Medicare guidelines to determine the circumstances under which claims for multiple surgeries will be eligible for reimbursement, in accordance with Health Net’s normal claims filing requirements. No benefit is payable for incidental surgical procedures, such as an appendectomy performed during gall bladder surgery. Covered Services and Supplies Page 47 Health Net uses available Medicare guidelines to determine which services and procedures are eligible for payment separately or as part of a bundled package, including but not limited to, which items are separate professional or technical components of services and procedures. Health Net also uses proprietary guide- lines to identify potential billing inaccuracies. Laboratory and Diagnostic Imaging (including X-ray) Services Laboratory and diagnostic imaging (including x-ray) services and materials are covered.

Preventive Care Services. Coverage is SAMPLE Preventive care services provided for preventive care Serviceson an outpatient basis at a Physician's office, includingan Alternate Facility or a Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law: 1. • Evidence-based items or Services services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, except that the recommendations of the United States Preventive Service Task Force regarding breast cancer including tobacco cessation interventions, annual physical exams, prostate screening, mammography and prevention issued adult routine eye exam and hearing exam during or around November 2009 are not considered to be currentan annual physical performed by a Primary Care Physician. Visit: xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx; 2You can find more information at xxxxx://xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx/uspstf/recommendation-topics/uspstf-a-and-b- recommendations. • Immunizations for routine use in children, adolescents and adults that have in effect a recommendation in effect from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involvedPrevention. A recommendation from the Advisory Committee on Immunization Practices of the CDC is considered to be: in effect after it has been adopted by the director of the CDC and for routine use if it is listed on the immunization schedules of the CDCYou can find more information at xxxxx://xxx.xxx.xxx/vaccines/hcp/acip-recs/index.html. Visit: xxx.xxx.xxx/xxxxxxxx/xxxx/XXXX; 3. • With respect to infants, children and adolescents: Evidence, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration, including routine eye exam during an annual physical performed by a Primary Care Physician and well-baby visits and care up to 47 months of age. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 4. You can find more information at xxxxx://xxxxxxxxx.xxx.xxx/AAP/PDF/periodicity_schedule.pdf or xxxxx://xxx.xxx.xxx/en/practice- management/bright-futures/bright-futures-family-centered-care/well-child-visits-parent-and-patient-education/. • With respect to women (to the extent not described in paragraph “a” above)women, evidence- informed such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. To see You can find more information at xxxxx://xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx/wellwomanchart/. Benefits include: ▪ Mammograms including digital breast tomosynthesis, magnetic resonance imaging, ultrasound or other modality and at such age intervals as recommended by the current guidelinesNational Comprehensive Cancer Network. This includes Covered Persons at risk for breast cancer who have a family history with one or more first or second degree relatives with breast cancer, visitprior diagnosis of breast cancer, positive testing for hereditary gene mutations or heterogeneously or dense breast tissue based on the breast imaging reporting and data system of the American College of Radiology. ▪ Voluntary family planning and contraceptive services, which include, but are not limited to the following services: xxxx://xxxx.xxxx.xxx; 5♦ Office visits and exams (including family planning counseling or consultations to obtain internally implanted time-release contraceptives or intrauterine devices). A voluntary Health Risk Assessment that can be completed by Members annually♦ Contraceptive medication, insertions and injections (e.g. Norplant, Depo-Provera). Written feedback provided to Members will include recommendations for addressing identified risks; 6♦ Contraceptive device fittings, insertions and removals (e.g. IUDs, diaphragms, cervical caps). All United States Food and Drug Administration (FDA) approved contraceptive ♦ Female sterilization methods, including surgical sterilization procedures (tubal ligation) and patient education implantable sterilization (e.g. Essure) and counseling associated anesthesia. You can find more information on contraceptive services and devices at xxx.xxx.xxx/xxxxxxxxx/xxxx- publications-women/birth-control-chart. • Counseling for all women with reproductive capacity; 7breastfeeding/lactation, genetic, nutrition, obesity in adults and children, sexually transmitted infections, domestic violence, skin cancer, and tobacco use. Routine prenatal care; 8• Voluntary male sterilization, including associated anesthesia. BRCA counseling • HIV pre-exposure prophylaxis (PrEP) and genetic testing. Any follow up Medically Necessary treatment is covered at the applicable Cost Share based upon type and place of service; and 9. Medically Necessary digital tomosynthesis, commonly referred to as three-dimensional “3_D”related services.

Preventive Care Services. Coverage is provided for preventive care Services, including: 1. Evidence-based items or Services that have in effect a rating of "A" or "B" in The coverage described below shall be consistent with the current recommendations requirements of the United States Affordable Care Act (ACA). Preventive Care Services are covered for children and adults, as directed by your Physician, based on the guidelines from the following resources: • U.S. Preventive Services Task Force, except that the Force Grade A & B recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography and prevention issued during or around November 2009 are not considered to be current. Visit: xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx; 2. Immunizations for routine use in children, adolescents and adults that have a recommendation in effect from the (xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx/xxxxxx/xxxxxxxxxx.xxx) • The Advisory Committee on Immunization Practices of (ACIP) that have been adopted by the Centers Center for Disease Control and Prevention (CDCxxx.xxx.xxx/xxxxxxxx/XXXX/xxxxx.xxxx) with respect to the individual involved. A recommendation from the Advisory Committee on Immunization Practices of the CDC is considered to be: in effect after it has been adopted by the director of the CDC and • Guidelines for routine use if it is listed on the immunization schedules of the CDC. Visit: xxx.xxx.xxx/xxxxxxxx/xxxx/XXXX; 3. With respect to infants, children children, adolescents and adolescents: Evidence-informed women’s preventive health care and screenings provided for in the comprehensive guidelines as supported by the Health Resources and Services AdministrationAdministration (HRSA) (xxx.xxxx.xxx/xxxxxxxxxxxxxxxx/) Your Physician will evaluate your health status (including, but not limited to, your risk factors, family history, gender and/or age) to determine the appropriate Preventive Care Services and frequency. To see The list of Preventive Care Services are available through xxx.xxxxxxxxxx.xxx/xxxx/xxxxxxxxxx/0000/00/xxxxxxxxxx-xxxxxxxx-xxxx.xxx Examples of Preventive Care Services include, but are not limited to: • Periodic health evaluations • Preventive vision and hearing screening • Blood pressure, diabetes, and cholesterol tests • USPSTF and HRSA recommended cancer screenings, including FDA-approved human papillomavirus (HPV) screening test, screening and diagnosis of prostate cancer (including prostate-specific antigen testing and digital rectal examinations), screening for breast, cervical and colorectal cancer, human immunodeficiency virus (HIV) screening, mammograms and colonoscopies • Developmental screenings to diagnose and assess potential developmental delays • Counseling on such topics as quitting smoking, lactation, losing weight, eating healthfully, treating depression, prevention of sexually transmitted diseases and reducing alcohol use • Routine immunizations against diseases such as measles, polio, or meningitis • Flu and pneumonia shots • Vaccination for acquired immune deficiency disorder (AIDS) that is approved for marketing by the current guidelinesFDA and that is recommended by the United States Public Health Service • Counseling, visit: xxxx://xxxx.xxxx.xxxscreening, and immunizations to ensure healthy pregnancies • Regular well-baby and well-child visits • Well-woman visits Preventive Care Services for women also include screening for gestational diabetes; 4sexually-transmitted infec- tion counseling; human immunodeficiency virus (HIV) counseling; FDA-approved contraception methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling. With respect One breast pump and the necessary supplies to women operate it (as prescribed by your Physician) will be covered for each pregnancy at no cost to the extent not described in paragraph “a” above)Member. This includes one retail-grade breast pump (either a manual pump or a standard electric pump) as prescribed by Your Physician. We will determine the type of equipment, evidence- informed preventive care whether to rent or purchase the equipment and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administrationvendor who provides it. To see the current guidelines, visit: xxxx://xxxx.xxxx.xxx; 5. A voluntary Health Risk Assessment that Breast pumps can be completed obtained by Members annually. Written feedback provided to Members will include recommendations for addressing identified risks; 6. All United States Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity; 7. Routine prenatal care; 8. BRCA counseling and genetic testing. Any follow up Medically Necessary treatment is covered calling the Customer Contact Center at the applicable Cost Share based upon type phone number on your Health Net ID card. Preventive Care Services are covered as shown in the "Schedule of Benefits and place Copayments" Section 200. Vision and Hearing Examinations Vision and hearing examinations for diagnosis and treatment, including refractive eye examinations, are covered as shown in the "Schedule of service; Benefits” section. Preventive vision and 9hearing screening are covered as Preven- tive Care Services. Medically Necessary digital tomosynthesisObstetrician and Gynecologist (OB/GYN) Self-Referral If you are a female Member you may obtain OB/GYN Physician services without first contacting your Primary Care Physician. If you need OB/GYN Preventive Care Services, commonly referred are pregnant or have a gynecology ailment, you may go directly to an OB/GYN Specialist or a Physician who provides such services in your Physician Group. If such services are not available in your Physician Group, you may go to one of the contracting Physician Group’s referral Physicians who provides OB/GYN services. (Each contracting Physician Group can identify its referral Physicians.) The OB/GYN Physician will consult with the Member’s Primary Care Physician regarding the Member’s condition, treatment and any need for Follow-Up Care. Copayment requirements may differ depending on the service provided. Refer to "Schedule of Benefits and Copayments," Section 200. Preventive Care Services are covered under the “Preventive Care Services” heading as three-dimensional shown in this section, and in “3_D”Schedule of Benefits and Copayments,” Section 200.