49 − Pneumococcal ( polysaccharide); − Zoster; − Hepatitis A; − Hepatitis B; − Meningococcal; and − Varicella. • Immunization vaccines for children from birth to age 18 — doses, recommended ages and recommended populations must be satisfied: − Hepatitis B; − Rotavirus; − Diphtheria/tetanus/per tussis; − Haemophilus influenzae type b; − Pneumococcal; − Inactivated Poliovirus; − Influenza; − Measles/mumps/rubella; − Varicella; − Hepatitis A; − Meningococcal; and − Human papillomavirus (HPV). Office Visit Coverage Preventive services are paid based on the Plan’s payment schedules for the individual services. However, there are situations in which an office visit may not be payable under the preventive services benefit. If the primary purpose of the office visit is n ot for a preventive item or service, then the Plan will impose cost sharing with respect to the office visit. The following conditions apply to payment for in - network office visits under the Preventive Service benefit. • If a preventive item or service is b illed separately from an office visit, then the Plan will impose cost sharing with respect to the office visit. • If the preventive item or service is not billed separately from the office visit, and the primary purpose of the office visit is the delivery of such preventive item or service, then the Plan will pay 100 percent for the office visit. • If the preventive item or service is not billed separately from the office visit, and the primary purpose of the office visit is not the delivery of such preventive item or service, then the Plan will impose cost sharing with respect to the office visit. For example, if a covered individual schedules an in - network office visit to discuss recurring abdominal pain, and during the office visit the individual has a blood pressure screening, the office visit will be covered subject to the Plan’s cost sharing requirements, e.g., the deductible, if not already satisfied, and coinsurance , or copayment , because the blood pressure screening was provided as part of an office visi t, for which the primary purpose was not to deliver recommended preventive items or services.

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