Summary of Covered Services for Healthy Kids
Benefit year July 1 - June 30
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| Santa Cruz County | Merced County |
|---|---|
|
Follow the links for more information about your health plan and coverage:
Health Education Benefits
|
Follow the links for more information about your health plan and coverage:
Health Education Benefits |
• Services must be obtained from a participating plan provider
• Read the Member Handbook/EOC for Specific Benefits
• Benefits are subject to Alliance Utilization Management
| Category Description | Member Copayment & Limitations |
|---|---|
| HOSPITAL SERVICES | |
Inpatient Room and Services Skilled Nursing (limited to 100 days/ benefit year) |
No Copayment No Copayment |
| PROFESSIONAL SERVICES | |
PHYSICIAN SERVICES |
|
| PREGNANCY AND MATERNITY CARE
Prenatal care (office visits) Normal delivery, cesarean section, complications of pregnancy, and medical services |
No Copayment |
| OTHER HEALTH CARE SERVICES | |
| ACUPUNCTURE (20 visits per benefit year) | $5 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 if authorized) | $5 per visit |
| DENTAL
Covered through Delta Dental, 1-877-580-1042 |
For a complete list of covered services and copay amounts, please see the EOC. |
| DIAGNOSTIC X-RAY/LAB PROCEDURES | No Copayment |
| DURABLE MEDICAL EQUIPMENT (including original and replacement orthotics and prosthetics) |
No Copayment |
| FAMILY PLANNING SERVICE
Medical, professional and counseling services FDA Approved Contraceptive drugs and devices prescribed by your doctor |
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 | No Copayment |
| HOSPICE (for a terminal illness) | No Copayment |
| MENTAL HEALTH CARE SERVICES
Inpatient (30 days per benefit year) |
No Copayment |
| PHYSICAL/OCCUPATIONAL/SPEECH THERAPY
In office or through home health care |
$5 per visit |
| PRESCRIPTION DRUGS
30-day supply 90-day supply for Maintenance Drugs |
|
SUBSTANCE ABUSE TREATMENT SERVICES |
No Copayment $5 per visit Covered through OptumHealth at 1-800-808-5796 |
| URGENT CARE SERVICES | $5 per visit Must be provided or arranged by your PCP |
| VISION CARE SERVICES | $5 per examination every 12-months Covered through Vision Services Plan (VSP) 1-800-877-7195 |
| DENTAL SERVICES | Covered through Delta Dental 1-877-580-1042 |
There are no deductibles or lifetime maximum limits on benefits under this plan. There is a $250 copayment maximum per family per benefit year.