50 Routine Mammography Screening Charges for routine screening for breast cancer by low - dose mammography that are listed below are covered medical charges if ordered by a physician or an Allied Health Professional. Mammog raphy screening charges include only: • Charges for a baseline mammogram for a covered individual age 35 but less than a ge 40. • C harges for a mammogram performed once every year for a covered individual age 40 and over. The term low - dose mammography means the x - ray examination of the breast using equipment dedicated specifically for mammography, including, but not limited to , the x - ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one r ad mid - breast, with two views for each breast. Family Planning Charges for family planning related services including medical history, physical exam, related laboratory tests, medical supervision in accordance with generally accepted medical practices, counseling on contraception, implanted or inj ected contraceptives, medical services connected with surgical therapies including t ubal ligation or vasectomy, are covered medical benefi ts (oral contraceptives are covered under the Prescription Drug Coverage) under the terms of the Plan. Other limitations that apply to preventive services will also app ly to family planning services. W omen’s Preventive Care Routine annual gynecological exam, annual Papanicolaou (PAP) screening, and routine mammography screening are provided by the Plan as specified above. The Plan also provides coverage for female participants as follows: • Gestational Di abetes Screening: Covered for women who are 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes. • HPV DNA Testing : Covered every three (3) years for women age 30 and over, r egardless of Pap smear results. • STI Counseling : Cover ed annually for sexually active women. An STI is a sexually transmitted infection. • HIV Screening and Counseling: Covered annu ally for sexually active women. • Contraception and Contraceptive Counseling: All FDA approved contraceptive methods, sterilization p rocedures, patient education and counseling. Oral contraceptives are covered under the Prescription Drug Coverag e • Breastfeeding Support, Supplies, and Counseling : Pregnant and postpartum women are covered for lactation support and counseling, and breastfeeding equipment. Breastfeeding equipment is limited to the rental of one breast pump per birth as ordered or prescribed by a physician or Allied Health Prof essional and related supplies. • Interpersonal and Domestic Violence Screening and Counseling : Adolescent and adult women are covered for screening and counseling for interpersonal and domestic violence. The Plan covers the above services in accordance with applicable federal guidelines. Covered services will be paid at 100%.