51 • Charges for a surgeon and an anesthesiologist who perform the procedure . • Charges for outpatient facility use at a Hospital or other approved surgical facility. • Charges for related professional interpretation services required as a result of surgery. Removal of polyps that are found during the routine screening are included. 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. Mammography screening charges include only: • Charges for a baseline mammogram for a covered individual age 35 but less than age 40. • Charges 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 usin g 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 rad mid - breast, with two views for eac h 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 o r injected contraceptives, medical services connected with surgical therapies including tubal ligation or vasectomy, are covered medical benefits (oral contraceptives are covered under the Prescription Drug Coverage) under the terms of the Plan. Other lim itations that apply to preventive services will also app ly to family planning services. Women’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 Diabetes 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 : Covered annually for sexually active women. An STI is a sexually transmitted infection. • HIV Screening and Counseling: Covered annu ally for sexually active women. • Contracept ion and Contraceptive Counseling: All FDA approved contraceptive methods, sterilization procedures, patient education and counseling. Oral contraceptives are covered under the Prescription Drug Coverag e • Breastfeeding Support, Supplies, and Counseling : Preg nant 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.