Central California Alliance for Health - Summary of Covered Services for MediCruz Advantage

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Summary of Covered Services for MediCruz Advantage

The MediCruz Advantage program provides quality, low-cost health care services to residents of Santa Cruz County who are low-income, uninsured and between the ages of 19 and 64. MediCruz Advantage members will be linked to a Primary Care Physician (PCP) as chosen by the County. The Alliance will provide administrative services for the program, including but not limited to, provider and member servicing, utilization management and claims payment.

Please note that MediCruz Advantage members are required to obtain an Authorized Referral for services rendered by specialists and eligibility for the program is determined by the County.

Please call your Provider Services representative with any questions at:
831-430-5500.

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• Benefits are subject to Alliance Utilization Management.

• For more information on this program, please visit the
Santa Cruz County website .

Follow the links for more information about the MediCruz Advantage health plan:

  Provider Manual

  Provider Directory

  Member Handbook

  Where to apply for benefit coverage

Category Description	Comments and Limitations
HOSPITAL SERVICES
Inpatient room and services Inpatient Physical and Speech Therapy Emergency room (services in and out of the Plan's Service Area and with Contracted and Non-Contracted Providers) Outpatient surgery - facility	Some services require prior authorization.
PROFESSIONAL SERVICES
PHYSICIAN SERVICES Primary Care Office Visits (includes primary care, adult immunizations and periodic physical exams) Specialty Care Office Visits Physician services in the hospital Outpatient surgery - professional	You must get primary care services from your Primary Care Provider. You must have a referral from your Primary Care Provider and prior authorization from the Alliance for specialty care.
OTHER HEALTH CARE SERVICES
AMBULANCE SERVICES
BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)
DIAGNOSTIC SERVICES Radiology Services Lab Services	Some imaging services require prior authorization from the Alliance.
DURABLE MEDICAL EQUIPMENT (includes prosthetics and orthotics)	You must have a prescription from your Primary Care Provider. Some equipment and supplies require prior authorization from the Alliance.
HEARING EXAMS Audiology exam
HOME HEALTH CARE	You must have a prescription from your Primary Care Provider and prior authorization from the Alliance.
MENTAL HEALTH SERVICES Inpatient Services Outpatient Services Other Services	Covered through the Santa Cruz County Mental Health Department. Up to 10 days per year in an acute care hospital, psychiatric hospital or psychiatric health facility. Prior authorization required from MediCruz Advantage. Crisis residential treatment. Up to 12 outpatient visits per year. Outpatient visits include assessment, individual or group therapy, crisis intervention, medication support and assessment. Prior authorization required from MediCruz Advantage. Psychiatric medications. Case management services.
NON-EMERGENCY MEDICAL TRANSPORTATION	Benefit is limited to transportation to and from covered medical appointments for members who meet criteria. Requires prior authorization from the Alliance.
OUTPATIENT REHABILITATIVE THERAPY SERVICES Physical Therapy Speech Therapy	You must have a referral from your Primary Care Provider and prior authorization.
PHARMACY SERVICES Prescription medication	Prescriptions must be written by a MediCruz Advantage provider. You must get your prescriptions at the Santa Cruz County pharmacy or other participating pharmacy in Santa Cruz County.
PODIATRY SERVICES	You must have a referral from your Primary Care Provider and prior authorization from the Alliance.
SUBSTANCE ABUSE SERVICES Outpatient Services	Up to 12 outpatient group visits per year. Case management.
URGENT CARE	Must be provided by your Primary Care Provider when you are inside of Santa Cruz County.