Central California Alliance for Health

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Summary of Covered Services for Healthy Families

Benefit year October 1 - September 30

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• Services must be obtained from a participating plan provider

• Read the Member Handbook/EOC for Specific Benefits

• Benefits are subject to Alliance Utilization Management

Follow the links for more information about your health plan and coverage:

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  Provider Directory

  Member Handbook

  Where to apply for benefit coverage

Category Description	Member Copayment & Limitations
HOSPITAL SERVICES
Inpatient Room and Services Inpatient physical, occupational and speech therapy Emergency Room (services in and out of the plan’s service area and with non-participating providers) Skilled Nursing (limited to 100 days/ benefit year)	No Copayment No Copayment $5 or $10 Copayment (waived if admitted directly to the hospital) No Copayment
PROFESSIONAL SERVICES
PHYSICIAN SERVICES Office Visits Physician services in the hospital Outpatient surgery Immunizations Periodic Physical Examinations	$5 or $10 per visit (except for children 0-24 months of age) No Copayment No Copayment No Copayment No Copayment
PREGNANCY AND MATERNITY CARE Prenatal care (office visits) Normal delivery, cesarean section, complications of pregnancy, and medical services	No Copayment No Copayment
OTHER HEALTH CARE SERVICES
ACUPUNCTURE (20 visits per benefit year)	$5 or $10 per visit
AMBULANCE SERVICES	No Copayment
BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)	No Copayment
CHIROPRACTIC (20 visits per benefit year)	$5 or $10 per visit
DIAGNOSTIC X-RAY/LAB PROCEDURES	No Copayment
DURABLE MEDICAL EQUIPMENT (including original and replacement orthotics and prosthetics)	No Copayment
FAMILY PLANNING SERVICES Medical, Professional and Counseling Services FDA Approved Contraceptive drugs and devices	No Copayment No Copayment (over-the-counter items are not covered, for example: condoms, jellies, or foams)
HEARING AIDS Audiology Exam Hearing Aid Instrument	No Copayment No Copayment
HOME HEALTH CARE SERVICES	No Copayment
HOSPICE (for a terminal illness)	No Copayment
MENTAL HEALTH CARE SERVICES Inpatient (30 days per benefit year) Outpatient (20 visits per benefit year) Limits do not apply to services for severe mental illness (SMI) or serious emotional disturbance (SED)	No Copayment $5 or $10 per visit through United Behavioral Health at 1-800-808-5796 Or visit their site at www.liveandworkwell.com
PHYSICAL/OCCUPATIONAL/SPEECH THERAPY In office or through home health care	$5 or $10 per visit
PRESCRIPTION DRUGS 30-day supply 90-day supply for Maintenance Drugs	$5 or $10 per prescription (except for contraceptive drugs) $5 or $10 per prescription
SUBSTANCE ABUSE Inpatient (30 days per benefit year) Outpatient (20 visits per benefit year)	No Copayment $5 or $10 per visit through United Behavioral Health at 1-800-808-5796 Or visit their site at www.liveandworkwell.com
URGENT CARE SERVICES	$5 or $10 per visit Must be provided or arranged by your PCP

There are no deductibles or lifetime maximum limits on benefits under this plan.