Expanded Benefits
Expanded benefits are extra goods or services we provide to you, free of charge. Call Member Services to ask about getting expanded benefits.
Equine Therapy
Equine therapy includes interactions between the member and horses to help improve behaviors and emotions.
COVERAGE/LIMITATIONS: Up to 10 therapy treatment sessions per year for 21+ years old. One evaluation/ re-evaluation per year.
PRIOR AUTHORIZATION: Plan OK Needed
Occupational Therapy
Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house.
COVERAGE/LIMITATIONS: Up to 7 therapy treatments unit per week for 21+ years old. One evaluation/ re-evaluation per year.
PRIOR AUTHORIZATION: Plan OK Needed
Physical Therapy
Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition.
COVERAGE/LIMITATIONS: Up to 7 therapy treatments unit per week for 21+ years old. One evaluation/ re-evaluation per year.
PRIOR AUTHORIZATION: Plan OK Needed
Hearing Services
Hearing tests, treatments, and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.
COVERAGE/LIMITATIONS: Please contact member services for more information 1-866-899-4828. Service is for 21+ years old.
PRIOR AUTHORIZATION: No Plan OK Needed
Vision Services
Visual Aids are items such as glasses and contact lenses.
COVERAGE/LIMITATIONS: Contact lenses - 6-month supply for 21+ years old. Frames – 1 per year for 21+ years old. Also includes one eye exam per year.
PRIOR AUTHORIZATION: Please contact 20/20 Vision at 1-877-296-0799
Prenatal Services
Services that ensure that you and your baby are healthy during and after your pregnancy.
COVERAGE/LIMITATIONS: Please contact member services for more information
1-866-899-4828. Plan OK needed for hospital grade breast pump rental.
PRIOR AUTHORIZATION: Please contact member services for more information 1-866-899-4828
Respiratory Therapy
Services to help you breathe better while being treated for a respiratory condition, illness or disease.
COVERAGE/LIMITATIONS: One (1) per day for 21+ years old. One evaluation/re-evaluation per year and one treatment per day; does not require plan OK.
PRIOR AUTHORIZATION: Plan OK Needed
Speech Therapy
Services that include tests and treatments to help you talk or swallow better.
COVERAGE/LIMITATIONS: Up to 7 therapy treatments units per week. One evaluation/re-evaluation per year, one evaluation of oral & pharyngeal swallowing function per year, one AAC initial evaluation per year, one AAC re-evaluation per year, and up to 4 30-minute sessions for AAC fitting, adjustment, & training visits per year; does not require plan OK.
PRIOR AUTHORIZATION: Plan OK Needed
Primary Care Services
Routine or sick visits to your Primary Care Physician (PCP) for adults 21+ years old.
COVERAGE/LIMITATIONS: Unlimited Visits
PRIOR AUTHORIZATION: No Plan OK Needed
Newborn Circumcision
Available upon request during the initial hospitalization visit and in physician offices within 12 weeks after birth. A limit of (1) per lifetime.
COVERAGE/LIMITATIONS: Available within the first (12) weeks of birth. One (1) per lifetime.
PRIOR AUTHORIZATION: No Plan OK Needed
CVS Discount Program
All enrollees will receive a CVS discount card providing 20% off purchases including Over the Counter medications.
COVERAGE/LIMITATIONS: 20% discount off certain OTC items.
PRIOR AUTHORIZATION: No Plan OK Needed
Doula Services
A non-medical person who stays with and assists you before, during, or after childbirth.
COVERAGE/LIMITATIONS: Unlimited per pregnancy
PRIOR AUTHORIZATION: No Plan OK Needed
Medically Related Home Care Services/Homemaker
Homemaker service for medical needs.
COVERAGE/LIMITATIONS: Two (2) carpet cleanings/year for enrollees with asthma.
PRIOR AUTHORIZATION: Plan OK Needed
Home Delivered Meals – Post Facility Discharge (Hospital or Nursing Facility)
Meal delivery after your inpatient hospital stay.
COVERAGE/LIMITATIONS: Ten (10) meals annually.
PRIOR AUTHORIZATION: No Plan OK Needed
Home Delivered Meals – Disaster Preparedness/Relief
Meal delivery before or after a natural disaster.
COVERAGE/LIMITATIONS: One (1) annually.
PRIOR AUTHORIZATION: No Plan OK Needed
Home Visit by a Clinical Social Worker
Services of a clinical social worker in home health or hospice setting.
COVERAGE/LIMITATIONS: 48 visits per year for 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Meals and Lodging – Non-emergency Transportation Daytrips
For non-emergency care when you have to travel a long distance.
COVERAGE/LIMITATIONS: $150 per stay.
PRIOR AUTHORIZATION: No Plan OK Needed
Nutritional Counseling
Provides you with information on the right type of foods to eat and based on your health needs.
COVERAGE/LIMITATIONS: Unlimited.
PRIOR AUTHORIZATION: Plan OK Needed
Swimming Lessons
Drowning Prevention Lessons.
COVERAGE/LIMITATIONS: Members up to age 11 are covered for up to $200 per year. This is limited to 1000 enrollees per year.
PRIOR AUTHORIZATION: Plan OK Needed
Vaccine – TdaP
Preventive Service.
COVERAGE/LIMITATIONS: One (1) vaccine per pregnancy
PRIOR AUTHORIZATION: No Plan OK Needed
Vaccine – Influenza
Preventive Service.
COVERAGE/LIMITATIONS: Unlimited.
PRIOR AUTHORIZATION: No Plan OK Needed
Vaccine – Shingles
Preventive Service.
COVERAGE/LIMITATIONS: One (1) per year.
PRIOR AUTHORIZATION: No Plan OK Needed
Vaccine – Pneumonia
Preventive Service.
COVERAGE/LIMITATIONS: Unlimited.
PRIOR AUTHORIZATION: No Plan OK Needed
Waived Copayments
All services, including behavioral health.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: No Plan OK Needed
Medication Assisted Treatment
Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Vaccine – Hepatitis A
Preventive Service.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: No Plan OK Needed
Housing Assistance
Supported Housing, per month.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Non-emergency Transportation - Non-Medical Purposes
Transportation: ancillary: parking fees, tolls, other.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Therapy - Art
Activity therapy, such as music, dance, art, or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more).
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Therapy - Pet
Activity therapy, such as music, dance, art, or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more).
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Hospital Bed
Durable Medical Equipment.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Glucose Monitoring
Durable Medical Equipment.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Assessment Services
Evaluation & Assessments.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Behavioral Health Day Services/Day Treatment
Behavior Health Day Treatment.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Behavioral Health Screening Services
Behavioral Health Screening Services.
COVERAGE/LIMITATIONS: Ages 21+ years old.
PRIOR AUTHORIZATION: Plan OK Needed
Plan Benefits
Addictions Receiving Facility Services
Services used to help people who are struggling with drug or alcohol addiction.
COVERAGE/LIMITATIONS: As medically necessary and recommended by us.
PRIOR AUTHORIZATION: Plan OK Needed
Allergy Services
Services to treat conditions such as sneezing or rashes that are not caused by an illness.
COVERAGE/LIMITATIONS: We cover blood or skin allergy testing and up to 156 doses per year of allergy shots, Copayment: $2.00 per office visit.
PRIOR AUTHORIZATION: No Plan OK Needed
Ambulance Transportation Services
Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities.
COVERAGE/LIMITATIONS: Covered as medically necessary.
PRIOR AUTHORIZATION: No Plan OK Needed
Ambulatory Detoxification Services
Services provided to people who are withdrawing from drugs or alcohol.
COVERAGE/LIMITATIONS: As medically necessary and recommended by us.
PRIOR AUTHORIZATION: Plan OK Needed
Ambulatory Surgical Center Services
Surgery and other procedures that are performed in a facility that is not the hospital (outpatient).
COVERAGE/LIMITATIONS: Covered as medically necessary.
PRIOR AUTHORIZATION: Plan OK Needed
Anesthesia Services
Services to keep you from feeling pain during surgery or other medical procedures.
COVERAGE/LIMITATIONS: Covered as medically necessary.
PRIOR AUTHORIZATION: No Plan OK Needed
Assistive Care Services
Services provided to adults (ages 18 and older) help with activities of daily living and taking medication.
COVERAGE/LIMITATIONS: We cover 365/366 days of services per year.
PRIOR AUTHORIZATION: No Prior Authorization is required when services are rendered in an Assisted Living Facility, Adult family care home, or Residential treatment facility.
Behavioral Health Assessment Services
Services used to detect or diagnose mental illnesses and behavioral health disorders.
COVERAGE/LIMITATIONS: We cover:
- - One initial assessment per year
- - One reassessment per year
- - Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Behavioral Health Overlay Services
Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program.
COVERAGE/LIMITATIONS: We cover 365/366 days of services per year, including therapy, support services and aftercare planning.
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Cardiovascular Services
Services that treat the heart and circulatory (blood vessels) system.
COVERAGE/LIMITATIONS: We cover the following as prescribed by your doctor:
- - Cardiac testing
- - Cardiac surgical procedures
- - Cardiac devices
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for certain invasive services.
Child Health Services Targeted Case Management
Services provided to children (ages 0 - 3) to help them get health care and other services.
COVERAGE/LIMITATIONS: Your child must be enrolled in the DOH Early Steps program.
PRIOR AUTHORIZATION: No Plan OK Needed
Chiropractic Services
Diagnosis and manipulative treatment of misalignments of the joints, especially the spinal column, which may cause other disorders by affecting the nerves, muscles, and organs.
COVERAGE/LIMITATIONS: We cover:
- - 24 established patient visits per year, per member
- - X-rays
Copayment: $1.00 per visit
PRIOR AUTHORIZATION: Plan OK Needed after 24 visits per year, up to a maximum of 37 visits.
Clinic Services
Health care services provided in a county health department, federally qualified health center, or a rural health clinic.
COVERAGE/LIMITATIONS: Copayment: $3.00 per visit to a federally qualified health center or rural health clinic visit.
PRIOR AUTHORIZATION: No Plan OK Needed
Crisis Stabilization Unit Services
Emergency mental health services that are performed in a facility that is not a regular hospital.
COVERAGE/LIMITATIONS: As medically necessary and recommended by us.
PRIOR AUTHORIZATION: No
Dialysis Services
Medical care, tests, and other treatments for the kidneys. This service also includes dialysis supplies, and other supplies that help treat the kidneys.
COVERAGE/LIMITATIONS: We cover the following as prescribed by your treating doctor:
- - Hemodialysis treatments
- - Peritoneal dialysis treatments
PRIOR AUTHORIZATION: Plan OK Needed
Durable Medical Equipment and Medical Supplies Services
Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches, and other items. Medical supplies are items meant for one-time use and then thrown away..
COVERAGE/LIMITATIONS: Some service and age limits apply. Call 1-866-899-4828 for more information.
PRIOR AUTHORIZATION: Prior Authorization is required for some Durable Medical Equipment and Medical Supplies.
Early Intervention Services
Services to children ages 0 - 3 who have developmental delays and other conditions.
COVERAGE/LIMITATIONS:
We cover:
- - One initial evaluation per lifetime, completed by a team
- - Up to 3 screenings per year
- - Up to 3 follow-up evaluations per year
- - Up to 2 training or support sessions per week
PRIOR AUTHORIZATION: No Plan OK Needed
Emergency Transportation Services
Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency.
COVERAGE/LIMITATIONS: Covered as medically necessary.
PRIOR AUTHORIZATION: No Plan OK Needed
Evaluation and Management Services
Services for doctor’s visits to stay healthy and prevent or treat illness.
COVERAGE/LIMITATIONS:
We cover:
- - One adult health screening (check-up) per year
- - Well child visits are provided based on age and developmental needs
- - One visit per month for people living in nursing facilities
- - Up to two office visits per month for adults to treat illnesses or conditions
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: No Plan OK Needed
Family Therapy Services
Services for families to have therapy sessions with a mental health professional.
COVERAGE/LIMITATIONS: We cover:
- - Up to 26 hours per year
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Gastrointestinal Services
Services to treat conditions, illnesses, or diseases of the stomach or digestion system.
COVERAGE/LIMITATIONS: We cover:
- - Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for invasive procedures.
Genitourinary Services
Services to treat conditions, illnesses, or diseases of the genitals or urinary system.
COVERAGE/LIMITATIONS: We cover:
- - Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for invasive procedures.
Group Therapy Services
Services for a group of people to have therapy sessions with a mental health professional.
COVERAGE/LIMITATIONS: We cover:
- - Up to 39 hours per year
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Hearing Services
Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.
COVERAGE/LIMITATIONS: We cover hearing tests and the following as prescribed by your doctor:
- - Cochlear implants
- - One new hearing aid per ear, once every 3 years
- - Repairs
PRIOR AUTHORIZATION: Plan OK Needed for Cochlear implants.
Home Health Services
Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury.
COVERAGE/LIMITATIONS: We cover:
- - Up to 4 visits per day for pregnant recipients and recipients ages 0 - 20
- - Up to 3 visits per day for all other recipients
Copayment: $2.00 per provider, per day
PRIOR AUTHORIZATION: Plan OK Needed
Hospice Services
Medical care, treatment, and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary
Copayment: See information on Patient Responsibility for copayment information; you may have Patient Responsibility for hospice services whether living at home, in a facility, or in a nursing facility.
PRIOR AUTHORIZATION: Plan OK Needed
Individual Therapy Services
Services for people to have one-to-one therapy sessions with a mental health professional.
COVERAGE/LIMITATIONS: We cover:
- - Up to 26 hours per year
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Inpatient Hospital Services
Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.
COVERAGE/LIMITATIONS:
We cover the following inpatient hospital services based on age and situation:
- - Up to 365/366 days for recipients ages 0 – 20
- - Up to 45 days for all other recipients (extra days are covered for emergencies)
PRIOR AUTHORIZATION: Plan OK Needed
Integumentary Services
Services to diagnose or treat skin conditions, illnesses or diseases.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Needed for invasive procedures.
Plan Benefits
Laboratory Services
Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary
Copayment: $1.00 per lab visit, $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for genetic testing.
Medical Foster Care Services
Services that help children with health problems who live in foster care homes.
COVERAGE/LIMITATIONS:
Must be in the custody of the Department of Children and Families.
PRIOR AUTHORIZATION: No Plan OK Needed
Medication Assisted Treatment Services
Services used to help people who are struggling with drug addiction.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for Authorization 1-800-294-8642.
Medication Management Services
Services to help people understand and make the best choices for taking medication.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary.
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: No Plan OK Needed
Mental Health Targeted Case Management
Services to help get medical and behavioral health care for people with mental illnesses.
COVERAGE/LIMITATIONS: Covered as medically necessary.
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642.
Neurology Services
Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system.
COVERAGE/LIMITATIONS: Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for some procedures
Non-Emergency Transportation Services
Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles.
COVERAGE/LIMITATIONS: We cover the following services for recipients who have no transportation:
PRIOR AUTHORIZATION: Plan OK Needed
Nursing Facility Services
Medical care or nursing care that you get while living full-time in a nursing facility. This can be a shortterm rehabilitation stay or long-term.
COVERAGE/LIMITATIONS: We cover 365/366 days of services in nursing facilities as medically necessary.
Copayment: See information on Patient Responsibility for room & board copayment information.
PRIOR AUTHORIZATION: Plan OK Needed
Occupational Therapy Services
Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house.
COVERAGE/LIMITATIONS:
We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap:
- - One initial evaluation per year
- - Up to 210 minutes of treatment per week
- - One initial wheelchair evaluation per 5 years
We cover for people of all ages:
- - Follow-up wheelchair evaluations, one at delivery and one 6-months later
PRIOR AUTHORIZATION: Plan OK Needed
Oral Surgery Services
Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary.
- - Copayment: $2.00 per office visit.
PRIOR AUTHORIZATION: Plan OK Needed for some procedures.
Orthopedic Services
Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.
COVERAGE/LIMITATIONS: Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for Invasive procedures and advanced imaging services (such as MRI or CAT scan).
Outpatient Hospital Services
Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.
COVERAGE/LIMITATIONS:
- - Emergency services are covered as medically necessary
- - Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over
Copayment: $15.00 or less for non-emergency services at an emergency room and $3.00 for all others
PRIOR AUTHORIZATION: Plan OK Needed for some invasive procedures and overnight hospital observation.
Pain Management Services
Treatments for long-lasting pain that does not get better after other services have been provided.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary. Some service limits may apply
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Plan OK Needed for Invasive procedures.
Physical Therapy Services
Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition.
COVERAGE/LIMITATIONS: We cover for children ages
0-20 and for adults under the $1,500 outpatient services cap:
- - One initial evaluation per year
- - Up to 210 minutes of treatment per week
- - One initial wheelchair evaluation per 5 years
We cover for people of all ages:
Follow-up wheelchair evaluations, one at delivery and one 6-months later
PRIOR AUTHORIZATION: Plan OK Needed except for initial evaluation and re-evaluations.
Podiatry Services
Medical care and other treatments for the feet.
COVERAGE/LIMITATIONS: We cover:
- - Up to 24 office visits per year
- - Foot and nail care
- - X-rays and other imaging for the foot, ankle and lower leg
- - Surgery on the foot, ankle or lower leg
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for Invasive surgery.
Prescribed Drug Services
This service is for drugs that are prescribed to you by a doctor or other health care provider.
COVERAGE/LIMITATIONS: We cover:
- - Up to a 34-day supply of drugs, per prescription
Refills, as prescribed
PRIOR AUTHORIZATION: Some medications require Prior Authorization. All covered medications are $0 copay.
Private Duty Nursing Services
Nursing services provided in the home to people ages 0 to 20 who need constant care
COVERAGE/LIMITATIONS: We cover up to 24 hours per day
PRIOR AUTHORIZATION: Plan OK Needed
Psychological Testing Services
Tests used to detect or diagnose problems with memory, IQ or other areas
COVERAGE/LIMITATIONS: We cover:
- - 10 hours of psychological testing per year
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642
Psychosocial Rehabilitation Services
Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.
COVERAGE/LIMITATIONS: We cover:
- - Up to 480 hours per year
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642
Radiology and Nuclear Medicine Services
Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable x-rays.
COVERAGE/LIMITATIONS:
- - Covered as medically necessary
Copayment: $1.00 per portable x-ray visit; $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for advanced imaging such as MRI or CAT scans. No Plan OK Needed for x-rays
Regional Perinatal Intensive Care Center Services
Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions.
COVERAGE/LIMITATIONS: Covered as medically necessary
PRIOR AUTHORIZATION: No Plan OK Needed
Reproductive Services
Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family.
COVERAGE/LIMITATIONS:
We cover family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old.
PRIOR AUTHORIZATION: No Plan OK Needed
Respiratory Services
Services that treat conditions, illnesses or diseases of the lungs or respiratory system.
COVERAGE/LIMITATIONS: We cover:
- - Respiratory testing
- - Respiratory surgical procedures
- - Respiratory device management
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Plan OK Needed for some invasive procedures and devices.
Respiratory Therapy Services
Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.
COVERAGE/LIMITATIONS: We cover:
- - One initial evaluation per year
- - One therapy re-evaluation per 6 months
- - Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)
PRIOR AUTHORIZATION: Plan OK Needed except for initial evaluation and re-evaluations.
Plan Benefits
Specialized Therapeutic Services
Services provided to children ages 0 - 20 with mental illnesses or substance use disorders.
COVERAGE/LIMITATIONS:We cover the following:
- - Assessments
- - Foster care services
- - Group home services
PRIOR AUTHORIZATION: Please contact Carisk for Authorization at 1-800-294-8642
Speech-Language Pathology Services
Services that include tests and treatments help you talk or swallow better.
COVERAGE/LIMITATIONS:We cover the following services for children ages 0 - 20:
- - Communication devices and services
- - Up to 210 minutes of treatment per week
- - One initial evaluation per year
We cover the following services for adults:
- - One communication evaluation per 5 years
PRIOR AUTHORIZATION: Plan OK Needed except for initial evaluation and re-evaluations.
Statewide Inpatient Psychiatric Program Services
Services for children with severe mental illnesses that need treatment in the hospital.
COVERAGE/LIMITATIONS:Covered as medically necessary for children ages 0-20
PRIOR AUTHORIZATION: Please contact Carisk for Authorization at 1-800-294-8642
Therapeutic Behavioral On-Site Services
Services provided by a team to prevent children ages 0-20 with mental illnesses or behavioral health issues from being placed in a hospital or other facility.
COVERAGE/LIMITATIONS:We cover:
- - Up to 9 hours per month
Copayment: $2.00 per visit
PRIOR AUTHORIZATION: Please contact Carisk for information at 1-800-294-8642
Transplant Services
Services that include all surgery and pre- and post-surgical care.
COVERAGE/LIMITATIONS:Covered as medically necessary
PRIOR AUTHORIZATION: Plan OK Needed
Visual Aid Services
Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes.
COVERAGE/LIMITATIONS:We cover the following services when prescribed by your doctor:
- - Two pairs of eyeglasses for children ages 0 - 20
- - Contact lenses
- - Prosthetic eyes
PRIOR AUTHORIZATION: Please contact 20/20 for Authorization at 1-877-296-0799
Visual Care Services
Services that test and treat conditions, illnesses and diseases of the eyes.
COVERAGE/LIMITATIONS:Covered as medically necessary
Copayment: $2.00 per office visit
PRIOR AUTHORIZATION: Please contact 20/20 for Authorization at 1-877-296-0799