62 - Diphtheria/tetanus/pertussis; - Measles/mumps/rubella (MMR); - Inactivated poliovirus; - Influenza; - Human papillomavirus (HPV); - Pneumococcal (polysaccharide); - Zoster; - Hepatitis A; - Hepatitis B; - Meningococcal - Mpox; and - Varicella; • Immunization vaccines for children from birth to age 18 — doses, recommended ages and recommended populations must be satisfied: - Respiratory syncytial virus; - Hepatitis B; - Rotavirus; - Diphtheria/tetanus/pertussis; - Haemophilus influenzae type b; - Pneumococcal; - Inactivated poliovirus; - COVID-19; - Influenza; - Measles/mumps/rubella; - Varicella; - Hepatitis A; - Meningococcal; - Dengue; - Mpox; 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 not for a preventive item or service, then the Plan will
BTF Summary Plan A/A+ Page 66 Page 68