Service Service Code Req. or Limit Code Req. or Limit children younger than 19 years of age years of age 90867 IC 90716 IC; Covered for members 90868 PA for >30 sessions per ≥ 19; available free of charge treatment1; course IC through the Massachusetts 90869 IC Immunization Program for 90899 IC children younger than 19 90935 For hospitalized members years of age only; not for chronic 90717 IC; Covered for members maintenance ≥ 19; available free of charge 90937 For hospitalized members through the Massachusetts only; not for chronic Immunization Program for maintenance children younger than 19 90945 For hospitalized members years of age only; not for chronic 90732 Covered for members 19; maintenance ≥ available free of charge 90947 For hospitalized members through the Massachusetts only; not for chronic Immunization Program for maintenance children younger than 19 90952 IC years of age 90953 IC 90733 IC; Covered for members 91110 PA ≥ 19; available free of charge 91111 PA through the Massachusetts 91299 IC Immunization Program for 92065 PA children younger than 19 92310 PA; includes supply of lenses years of age 92311 PA; includes supply of lenses 90734 IC; Covered for members 92312 PA; includes supply of lenses ≥ 19; available free of charge 92313 PA; includes supply of lenses through the Massachusetts 92326 PA Immunization Program for 92499 IC children younger than 19 92507 PA for ST >35 years of age 92508 PA for ST >35 90736 IC; PA is required for 92521 PA for ST >35 members younger than age 50 92522 PA for ST >35 90738 IC 92523 PA for ST >35 90739 IC; Covered for members ≥19 92524 PA for ST >35 90749 IC 92526 PA for ST >35 90750 IC; PA required for members 92558 IC younger than age 50 92610 PA for ST >35 90756 Covered for members 19; 92700 IC ≥ available free of charge 92921 IC through the Massachusetts 92925 IC Immunization Program for 92929 IC children younger than 19 92934 IC
Service Code Req. or Limit children younger than 19 years of age 90716 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90717 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90732 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90733 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90734 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90736 IC; PA is required for members younger than age 50 90738 IC 90739 IC; Covered for members ≥19 90749 IC 90750 IC; PA required for members younger than age 50 90756 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 Service Code Req. or Limit years of age 90867 IC 90868 PA for >30 sessions per course treatment1; IC 90869 IC 90899 IC 90935 For hospitalized members only; not for chronic maintenance 90937 For hospitalized members only; not for chronic maintenance 90945 For hospitalized members only; not for chronic maintenance 90947 For hospitalized members only; not for chronic maintenance 90952 IC 90953 IC 91110 PA 91111 PA 91299 IC 92065 PA 92310 PA; includes supply of lenses 92311 PA; includes supply of lenses 92312 PA; includes supply of lenses 92313 PA; includes supply of lenses 92326 PA 92499 IC 92507 PA for ST >35 92508 PA for ST >35 92521 PA for ST >35 92522 PA for ST >35 92523 PA for ST >35 92524 PA for ST >35 92526 PA for ST >35 92558 IC 92610 PA for ST >35 92700 IC 92921 IC 92925 IC 92929 IC 92934 IC