Summary of Covered Services for
ViaCare Monterey County
 ViaCare Monterey County


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• Services must be obtained from a participating 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:

 

  Provider Directory

  Member Handbook

  Where to apply for benefit coverage



Category Description Comments and 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 Contracted and Non-Contracted Providers)

Outpatient surgery - facility
Some services require prior authorization from the Alliance.
PROFESSIONAL SERVICES  

PHYSICIAN SERVICES
Office Visits (includes primary and specialty care and periodic physical exams)

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 Services are covered as medically necessary.
BLOOD AND BLOOD PRODUCTS
(includes collection and storage of autologous blood)
Services are covered as medically necessary.
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 supplies and equipment require prior authorization from the Alliance.
HEARING EXAMS AND SERVICES
Audiology exam and hearing aid instrument
Requires prior authorization from the Alliance.
HOME HEALTH CARE You must have a prescription from your provider and prior authorization from the Alliance.
HOSPICE CARE Hospice services are covered for members who are diagnosed with a terminal illness and who choose or elect hospice care.
MENTAL HEALTH SERVICES
Inpatient Services







Outpatient Services

Inpatient hospitalization in an acute care hospital or psychiatric hospital. Requires prior authorization by ViaCare Monterey County.

Crisis and transitional residential services.

Outpatient visits include assessment, individual or group therapy, crisis intervention, medication support and assessment. Requires prior authorization by ViaCare Monterey County.

Day treatment.

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

Occupational Therapy

Speech Therapy
You must have a referral from your Primary Care Provider and prior authorization from the Alliance.
PHARMACY SERVICES You must have a prescription or a provider order. If the prescribed medication is not on the ViaCare Monterey County formulary, prior authorization must be obtained from the Alliance.
PODIATRY SERVICES You must have a referral from your Primary Care Provider and prior authorization from the Alliance.
URGENT CARE Must be provided by your Primary Care Provider when you are inside of Monterey County.

 

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