MEDI-CAL SUMMARY OF BENEFITS
Benefits are for full scope Medi-Cal Beneficiaries.
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• Services must be obtained from a participating Medi-Cal provider.
• Benefits are subject to Alliance Utilization Management.
Follow the links for more information about your health plan and coverage:
|Category Description||Comments and Limitations|
Inpatient Room and Services
Intermediate or Skilled Nursing Services
Emergency Room (services in and out of the plan’s service area and with non-participating providers)
|All non-emergency hospital services require prior authorization.|
|You must get services from your Primary Care Provider (PCP). If your PCP cannot provide the service, he or she will refer you to another provider.
Some services require prior authorization.
|PREGNANCY AND MATERNITY CARE
Prenatal care (office visits)Normal delivery, cesarean section, complications of pregnancy, and medical services
|Members may get prenatal and maternity care from any OB/GYN within the Service Area that accepts Medi-Cal and the Alliance.|
|OTHER HEALTH CARE SERVICES|
|AMBULANCE SERVICES||Covered when medically necessary.|
|BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)||Covered when medically necessary.|
|DENTAL||Covered through Denti-Cal (1-800-322-6384), not the Alliance.
|DIAGNOSTIC X-RAY/LAB PROCEDURES||Covered when medically necessary. Some services require prior authorization.|
|DURABLE MEDICAL EQUIPMENT
Covered when medically necessary. Prior authorization may be required.
|Covered when medically necessary. Prior authorization may be required.|
|COMMUNITY-BASED ADULT SERVICES (CBAS)||Covered when medically necessary. Prior authorization is required.|
|FAMILY PLANNING SERVICES
Medical, Professional and Counseling ServicesFDA-approved contraceptive drugs and devices
|Members may get these services from any provider that accepts Medi-Cal and the Alliance. Some FDA-approved over-the-counter items, such as condoms, foams and jellies are covered with a prescription|
Audiology Exam and Hearing Aid Instrument
|Covered when medically necessary. Prior authorization is required for hearing aids.|
|HOME HEALTH CARE||Covered when medically necessary. Prior authorization is required.|
|HOSPICE (for a terminal illness)||Covered when medically indicated and as decided by the Member.|
|ACUPUNCTURE AND CHIROPRACTIC SERVICES||Acupuncture and chiropractic services are covered for:
• Members under 21 years of age
• Members residing in a skilled or intermediate nursing facility
• Members who are pregnant, if the benefit is part of their pregnancy-related services or for services to treat a condition that might complicate their pregnancy.
Chiropractic services are also covered for any member if provided at a Federally Qualified Health Center (FQHC) that offers these services in accordance with clinic policy.
MENTAL HEALTH SERVICES
Outpatient Mental Health Services
Services for the treatment of mild or moderate mental health conditions.
Inpatient and Specialty Mental Health Services
Inpatient mental health services and services for the treatment of severe mental health conditions.
These services are provided through Beacon Health Strategies, 1-855-765-9700.
These services are covered through County Mental Health Departments, not the Alliance.
Santa Cruz County: 1-800-952-2335
Monterey County: 1-888-258-6029
Merced County: 1-888-334-0163
NON-EMERGENCY MEDICAL TRANSPORTATION
|Benefit limited to transportation to and from covered medical appointments for members who:
• Have a physical or medical condition that prevents them from riding in a bus or car;
• Must be transported lying down;
• Are in a wheelchair and not able to move out of the chair into a seat or to push the chair themselves.
Members who feel they meet the above criteria should call 800-700-3874 ext. 5625.
30-day supply; 90-day supply for maintenance drugs.
Members must get their prescriptions at a network pharmacy.
Dual eligible Alliance members (members with both Medicare and Medi-Cal) will have most of their medications covered through their Medicare Part D or Medicare Advantage Plan. There are some medications that are excluded from Medicare Part D that the Alliance would still be responsible for.
|NUTRITIONAL FORMULAS AND SUPPLEMENTS||
Covered when medically necessary. Prior authorization is required.
|REHABILITATIVE (PHYSICAL, OCCUPATIONAL AND SPEECH) AND HABILITATIVE THERAPY||The initial evaluation visit requires a referral from the member's Primary Care Provider. Any subsequent visits/treatments require prior authorization from the Alliance.|
|SUBSTANCE ABUSE DISORDER SERVICES||Covered through each County under fee-for-service Medi-Cal, not the Alliance.|
|URGENT CARE||Provided or arranged by your PCP|
|VISION||All members may get a routine eye exam every 2 years.
Glasses (lenses and frames) are covered every 2 years only for members under 21 years of age and those who are in a skilled or intermediate nursing facility.
Routine vision services for Alliance members are provided through Vision Services Plan (VSP) at 1-800-438-4560. Members must receive these services from a contracted provider.