The following preventive services and immunizations do not apply to all health plans administered or insured by your Blue Plan. 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 to any of the preventive services and immunizations in this document, they will be covered by your health 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.
Healthcare Reform Preventive Care Services |
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Preventive Services for Adults |
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Abdominal Aortic Aneurysm Screening |
Age 65-75 one screening per lifetime (men only with any history of smoking) |
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Alcohol Misuse Screening and Behavioral Counseling Interventions |
One per calendar year |
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Ambulatory Blood Pressure Monitoring |
Once per lifetime to confirm the diagnosis of hypertension |
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Blood Pressure Screening |
Included as part of an office visit |
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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 |
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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.) |
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Age 45-75, one per calendar year |
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Age 45-75, every 3 years |
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Age 45-75, every 10 years |
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Age 45-75, every 5 years |
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Age 45-75, every 3 years |
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Age 45-75, every 3 years |
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Depression, Anxiety and Suicide Risk Screening |
Three per calendar year |
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Diabetes Screening |
Age 19 and older, every 3 years |
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Diet Counseling (Adults with high risk for chronic diseases) |
Age 18 and older, three hours each calendar year |
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Fall Prevention Screening |
Age 65 and older. Exercise, physical therapy and vitamin D supplementation |
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Hepatitis B Screening |
One per calendar year |
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Hepatitis C Screening |
Once per lifetime; Once per year for individuals at high risk for infection |
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HIV Infection Prevention: Pre-exposure Prophylaxis (PrEP) |
Antiretroviral medication to be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines:
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HIV Screening |
No frequency limit |
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Immunizations |
See below for a complete list of covered immunizations |
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Lung Cancer Screening |
Age 50-80, one per calendar year |
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Prostate Screening (PSA) |
Men age 40 and older, one per calendar year |
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Preventive Office Visit |
One per calendar year |
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Sexually Transmitted Infection (STI) Prevention Counseling |
One per calendar year |
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Tobacco Use Counseling |
8 per calendar year |
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Tuberculosis Infection Screening |
Age 19 and older (adults at risk), one per calendar year |
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Preventive Services for Women (Including Pregnant Women) |
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Bacteriuria (Pregnant Women) |
With pregnancy |
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BRCA Counseling about genetic testing for women at higher risk |
Once in a lifetime |
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Breast Cancer Chemoprevention Counseling |
Once in a lifetime |
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Breast Cancer Screenings |
Age 35-39 one baseline screening mammogram, age 40 and older one screening mammogram per calendar year |
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Breastfeeding Support |
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Twice per calendar year |
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Five per year in conjunction with a birth |
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One electric breast pump allowed per pregnancy |
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Cervical Cancer Screening (Pap Smear) |
One per calendar year |
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Chlamydia Screening |
One per calendar year |
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Contraceptive Methods and Counseling |
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One per calendar year |
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One procedure per lifetime |
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Two per lifetime |
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One 12-month subscription per calendar year *Coverage includes member reimbursement for the cost of the FDA-approved, cleared, or granted mobile device applications for use an contraception consistent with FDA-approved, clear, or granted indication. |
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Gonorrhea Screening |
Twice per calendar year |
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Healthy Weight Gain in Pregnancy Counseling |
Three hours per calendar year |
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Hepatitis B Screening |
One per calendar year for pregnant women |
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HIV Screening |
No frequency limit |
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HIV Counseling |
One per calendar year |
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Human Papillomavirus (HPV) Screening |
Age 30 and older, every 3 years |
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Iron Deficiency Anemia Screening |
One per calendar year for pregnant women |
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Osteoporosis Screening |
Age 65 and older, 65 and younger if at risk, once every 2 years |
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Patient Navigation Services for Breast and Cervical Cancer Screening (Effective 1/1/26) |
Included in preventive office visit |
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Perinatal Depression Prevention Interventions |
Three hours per calendar year |
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Preconception Visit |
One visit per calendar year |
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Prenatal Care |
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Preeclampsia Screening |
Included in prenatal office visit |
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Prenatal Conference (Pediatrician only) |
With pregnancy |
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Preventing Obesity in Midlife Women |
Age 40 to 60 years, one hour per year |
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Rh Incompatibility Screening (All Pregnant Women) |
Twice per calendar year |
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Screening and Counseling for Interpersonal and Domestic Violence |
One per calendar year |
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Screening for Diabetes after Pregnancy |
Two per calendar year |
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Screening for Diabetes during Pregnancy |
Two per calendar year |
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Sexually Transmitted Infection (STI) Prevention Counseling |
One per calendar year |
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Syphilis Screening |
No frequency limit |
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Tobacco Use Counseling (Pregnant Women) |
8 per calendar year |
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Well Women Preventive Office Visit |
Up to two visits per calendar year depending on diagnosis and procedure |
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Preventive Services for Children |
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Alcohol and Drug Use Assessments (Adolescents) |
Age 11-21, one per calendar year |
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Behavior Counseling to Prevent Skin Cancer |
Age 6 months - 24 years (included in preventive office visit) |
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Cervical Cancer Screening (Pap Smear) |
One per calendar year |
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Congenital Hypothyroidism (Newborns) |
Age 2-4 days |
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Dental Caries Prevention (< age 5) |
Age birth - 5 years, 4 per calendar year |
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Dental Caries Prevention (Preschool Children) |
Included in preventive office visit |
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Depression, Anxiety and Suicide Risk Screening |
Age 8 and older, three per calendar year |
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Developmental Screening (< age 3) |
Age birth - 30 months, 5 screenings |
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Developmental Surveillance |
Included as part of an office visit |
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Dyslipidemia |
Age 2-10, one every 2 years |
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Gonorrhea Prevention (Eye Meds for Newborns) |
At delivery, included in standard inpatient newborn care |
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Hearing Screening - Newborns |
Age birth - 31 days, once in age range |
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Hearing Screening |
Age 2 months - 10 years, up to 8 tests during age range |
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Hematocrit or Hemoglobin Screening |
Age 4 months - 10 years, 3 services during age range |
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Hemoglobinopathies (Sickle cell screening for newborns) |
Age birth - 31 days |
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Hepatitis B Screening |
Age 11 and older, one per calendar year |
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High Body Mass Index in Children and Adolescents Interventions |
Age 6-17 years, 26 services per year |
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HIV Screening |
No frequency limit |
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Immunizations |
See below for a complete list of covered immunizations |
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Lead Screening |
Age 6 months - 6 years, 3 services during age range |
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Maternal Depression Screening |
Age birth - 6 months, 4 services during age range |
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Metabolic Hemoglobin Screening - Newborns |
Age birth - 2 months, once in age range |
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Oral Health Risk Assessment |
Age 6 months - 6 years, 3 services during age range |
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Routine Newborn Care (in hospital) |
Included in standard inpatient newborn care |
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Phenylketonuria (PKU for newborns) |
Age 2-14 days, 2 services during age range |
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Psychosocial/Behavioral Assessment |
Age Newborn - 21 years, 31 services during age range |
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Preventive Office Visit |
9 visits first two years of life |
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Sexually Transmitted Infections counseling (STI - adolescents at high risk) |
Age 10 and older, one per calendar year |
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Sexually Transmitted Infections Screening (STI - adolescents at high risk) |
Age 11 - 21, no frequency limit |
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Sudden Cardiac Arrest and Sudden Cardiac Death Screening |
Age 11 - 21, included in preventive office visits |
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Tuberculin Testing |
Age 1 month - 21 years, 6 services during age range |
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Vision Screening (Visual Acuity) |
Birth - 10 years, 8 services in age range |
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Immunizations(Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, and dosage. Refer to the CDC website to view the schedules: cdc.gov/vaccines/schedules/index.html) |
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COVID-19 vaccine |
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Diphtheria, tetanus, and acellular pertussis vaccine (DTaP) |
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DTaP, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV) |
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DTaP, inactivated poliovirus, and Haemophilus influenzae type b vaccine (DTaP-IPV/Hib) |
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DTaP and inactivated poliovirus vaccine (DTaP-IPV) |
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DTaP, inactivated poliovirus, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP-IPV-Hib-HepB) |
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Haemophilus influenzae type b vaccine (Hib) |
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Hepatitis A vaccine (HepA) |
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Hepatitis B vaccine (HepB) |
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Hepatitis A and Hepatitis B vaccine (HepA-HepB) |
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Human papillomavirus vaccine (HPV) |
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Influenza vaccine (inactivated, egg-based, cell-culture; recombinant; live, attenuated; high-dose) |
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Measles, mumps, and rubella vaccine (MMR) |
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Measles, mumps, rubella, and varicella vaccine (MMRV) |
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Meningococcal serogroups A, C, W, Y vaccine (MenACWY-CRM; MenACWY-TT) |
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Meningococcal serogroup B vaccine (MenB-4C; MenB-FHbp) |
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Meningococcal serogroups A, B, C, W, Y vaccine (MenACWY-TT/MenB-FHbp; MenACWY-CRM/MenB-4C) |
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Mpox vaccine (Mpox) |
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Pneumococcal conjugate vaccine (PCV15; PCV20; PCV21) |
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Pneumococcal polysaccharide vaccine (PPSV23) |
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Poliovirus vaccine (inactivated) (IPV) |
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Respiratory syncytial virus vaccine/monoclonal antibody (RSV; RSV-mAb) |
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Rotavirus vaccine (RV1; RV5) |
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Tetanus and diphtheria vaccine (Td) |
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Tetanus, diphtheria, and acellular pertussis vaccine (Tdap) |
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Varicella vaccine (VAR) |
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Zoster vaccine, recombinant (RZV) |
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Pharmacy Benefits(To be considered under the pharmacy plan when ordered by a physician and requires a prescription to be filled by the pharmacy.) |
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Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication |
Women only |
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Contraceptives |
Women only; generic only |
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Fluoride |
Ages 6-16 years |
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Folic Acid |
Ages 6-16 years |
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Breast Cancer Preventive Drugs |
Women age 35 and older |
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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 |
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Iron Supplements |
Ages 6-12 months |
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Statin Medications |
Ages 40-75 years with one or more cardiovascular risk factors and calculated |
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Prevention of HIV Infection: Pre-exposure Prophylaxis (PrEP) |
The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines:
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Revised 07/26 LR