Summary of Covered Services for IHSS
Benefit year July 1 - June 30
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• Services must be obtained from a participating plan provider • Benefits are subject to Alliance Utilization Management |
Follow the links for more information about your health plan and coverage:
Health Education Benefits |
| Category Description | Member Copayment & Limitations |
|---|---|
| HOSPITAL SERVICES | |
Inpatient Room and Services Skilled Nursing (limited to 100 days/ benefit year) |
No Copayment No Copayment $25 Copayment (waived if admitted directly to the hospital) 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) | $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) | $10 per visit |
| 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 on the plan formulary |
No Copayment $5 per prescription for generic, $15 brand name |
| 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
Inpatient Outpatient |
No Copayment $10 per visit Covered through OptumHealth at 1-800-808-5796 |
| PHYSICAL/OCCUPATIONAL/SPEECH THERAPY In office or through home health care |
$10 per visit |
| PRESCRIPTION DRUGS
30-day supply
90-day supply for Maintenance Drugs |
$5 per prescription for generic, $15 brand name
$5 per prescription for generic, $15 brand name
|
SUBSTANCE ABUSE |
No Copayment |
| URGENT CARE SERVICES | $10 per visit Must be provided or arranged by your PCP |
No deductibles or lifetime maximum limits on benefits under this plan. Copayment maximum $3,000 per benefit year.