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My Benefit Plans
Overview Benefit Details Member Details Care Plans Historical Benefit Plans

Benefit Details
The information on this page shows highlights of your plan's coverage. For a complete list of benefits, exclusions and/or limitations, please review your plan
materials. Benefit information listed here may be subject to change based upon State and Federal Guidelines. If you have any questions, please call us @ 1-800-303-
9626 (TTY:711) or visit our website @ http://www.metroplus.org/. (http://www.metroplus.org/)

Outpatient Services

Primary Care Visit - In Network $0 copay No Auth

Primary Care Visit - Out of Network Covered Auth required

Outpatient Facility Fee - In Network Covered Auth required for all emergent and
elective admissions

Outpatient Facility Fee - Out of Network Covered Auth required for all emergent and
elective admissions

Home Health Care Services - In Network Covered Auth required

Home Health Care Services - Out of Network Covered Auth required

Preadmission Testing - In Network Covered Auth required

Preadmission Testing - Out of Network Covered Auth Required

Private-Duty Nursing - In Network $0 copay Auth required

Private-Duty Nursing - Out of Network Covered Auth required

Ambulatory Surgery Center - In Network Covered Auth rules are at CPT code level

Ambulatory Surgery Center - Out of Network Covered Auth rules are at CPT code level

Specialist Visit - In Network $0 copay No Auth

Office Surgery - In Network Covered No Auth

Office Surgery - Out of Network Covered Auth required

English (United States)
 Outpatient Hospital Observation - In Network Covered No Auth

Outpatient HospitalMy
Home (/Members/s/) Observation - Out(/Members/s/my-plans-home-page)
Benefit Plans of Covered NoMy
Auth
Claims (/Members/s/my-claims-home-page)
Network

Podiatry Services - In Network Not Covered Not Covered

Podiatry Services - Out of Network Not Covered Not Covered

Services Performed in a Freestanding Radiology $0 copay Authorization is required for 2nd or

Facility - In Network more spinal MRIs performed within
a 12-month period. Authorization is
required for all PET Scans.

Services Performed in a Freestanding Radiology Covered Auth required

Facility - Out of Network

Specialist Visit - Out of Network Covered Auth required

Other Practioner Office Visit - In Network $0 copay No Auth

Other Practioner Office Visit - Out of Network Covered Auth required

Allergy Testing - In Network Covered No Auth

Allergy Testing - Out of Network Covered Auth required

Outpatient Surgery Physician/Surgical Services - Covered Auth rules are at CPT code level
In Network

Outpatient Surgery Physician/Surgical Services - Covered Auth rules are at CPT code level
Out of Network

Hospitalization

Inpatient Hospital Services - In Network $0 copay Authorization is required for all

emergent and elective admissions

Inpatient Hospital Services - Out of Network Covered Authorization is required for all
emergent and elective admissions

Inpatient Physician and Surgical Services - In $0 copay Please call Customer Service at 800-
Network 303-9626 to inquire about
authorization rules for particular
CPT codes

Inpatient Physician and Surgical Services - Out Covered Please call Customer Service at 800-
of Network 303-9626 to inquire about
authorization rules for particular
CPT codes

English (United States)

 Delivery and All Inpatient Services for Maternity Covered Auth required for elective
Care - In Network admissions for pre-planned
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) caesarean
My Claims section deliveries Auth
(/Members/s/my-claims-home-page)
not required for emergency
admissions for spontaneous labor
deliveries (vaginal and c-section)

Delivery and All Inpatient Services for Maternity Covered Auth is required for elective
Care - Out of Network admissions for pre-planned
caesarian section deliveries Auth
not required for emergency
admission for spontaenous labor
deliveries (vaginal and c-section)

Skilled Nursing Facility - In Network $0 copay Auth required

Skilled Nursing Facility - Out of Network Covered Auth required

Preventive and Wellness Services and Chronic Disease Management

Wellness and Healthcare Planning - In Network Not Covered Not Covered

Wellness and Healthcare Planning - Out of Not Covered Not Covered

Network

Gym Membership Reimbursement - In Network Not Covered

Prostate Cancer Screening - In Network Covered No auth

Prostate Cancer Screening - Out of Network Covered Auth required

All Other Preventive Services required by Covered No Auth

USPSTF and HRSA - In Network

All Other Preventive Services required by Covered Auth required

USPSTF and HRSA - Out of Network

Adult Immunizations - In Network Covered No Auth

Adult Immunizations - Out of Network Covered Auth required

Bone Density Testing - In Network Covered No Auth

Bone Density Testing - Out of Network Covered Auth required

Breast Cancer Screening (Mammogram) - In Covered Auth required for Breast MRI only
Network

Breast Cancer Screening (Mammogram) - Out of Covered Auth required for Breast MRI only
Network

English (United States)

 Cardiovascular Disease Risk Reduction Visit - In Covered Auth required if medically
Network necessary
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Cardiovascular Disease Risk Reduction Visit - Covered Auth required
Out of Network

Cardiovascular Disease Testing - In Network Covered No Auth

Cardiovascular Disease Testing - Out of Network Covered Auth required

Prostate Cancer Screenings - In Network Covered No Auth

Cervical and Vaginal Cancer Screening - In Covered No Auth

Network

Cervical and Vaginal Cancer Screening - Out of Covered Auth required

Network

Colorectal Cancer Screening - In Network Covered No Auth

Colorectal Cancer Screening - Out of Network Covered Auth required

Depression Screening - In Network Covered No Auth

Depression Screening - Out of Network Covered Auth required

Diabetes Screening - In Network $0 copay No Auth

Diabetes Screening - Out of Network Covered Auth required

DNA Based Colorectal Screening - In Network Covered No auth

DNA Based Colorectal Screening - Out of Covered Auth required

Network

Prostate Cancer Screenings - Out of Network Covered Auth required

HIV Screening - In Network Covered No Auth

HIV Screening - Out of Network Covered Auth required

Obesity Screening and Therapy - In Network Covered No Auth

Obesity Screening and Therapy - Out of Covered Auth required

Network

One-Time Screening Ultrasound - In Network $0 copay No Auth

One-Time Screening Ultrasound - Out of Covered Auth required

Network

English (United States)

 Postnatal Care - In Network Covered No Auth

Routine Gynecological
Home (/Members/s/) My Services/Well
Benefit PlansWoman Covered
(/Members/s/my-plans-home-page) NoMy
Auth
Claims (/Members/s/my-claims-home-page)
Exams - In Network

Routine Gynecological Services/Well Woman Covered Auth required

Exams - Out of Network

Screening for Lung Cancer with Low Dose Covered Auth required
Computed Tomography - Out of Network

Screening for Lung Cancer with Low Dose Covered No auth

Computed Tomography (LDCT) - In Network

Sterilization Procedures for Women - In Network$0 copay Subject to copayments or

coinsurance

Sterilization Procedures for Women - Out of Covered Auth required

Network

Postnatal Care - Out of Network Covered Auth required

Well Child Visits and Immunizations - In Covered No Auth

Network

Well Child Visits and Immunizations - Out of Covered Auth required

Network

Adult Annual Physical Examinations - In Covered No Auth

Network

Adult Annual Physical Examinations - Out of Covered Auth required

Network

Emergency Services

Urgent Care Centers or Facilities - In Network Covered No Auth

Urgent Care Centers or Facilities - Out of Not covered Not covered for non-participating
Network providers except for providers in
District of Columbia, Puerto Rico,
Guam, the Virgin Islands, Northern
Mariana Islands and American
Samoa

Emergency Room Services - In Network $0 copay No Auth

Emergency Room Services - Out of Network $0 copay No Auth

Emergency Transportation/Ambulance - In Covered Auth required only for air

Network ambulance services
English (United States)
 Emergency Transportation/Ambulance - Out of Covered Auth required only for air
Network ambulance services
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Laboratory Outpatient and Professional Services

Imaging (CT/PET Scans, MRIs) - In Network $0 copay Auth is required for 2nd or more
spinal MRIs performed within a 12-
month period. Auth is required for
all PET scans.

Imaging (CT/PET Scans, MRIs) - Out of Network Covered Auth is required for 2nd or more
spinal MRIs performed within a 12-
month period. Auth is required for
all PET scans.

Therapeutic Radiology Services - In Network Covered No auth

Therapeutic Radiology Services - Out of Covered Auth required

Network

X-Rays and Diagnostic Imaging - In Network $0 copay Auth is required for 2nd or more
spinal MRIs performed within a 12-
month period. Auth is required for
all PET scans.

X-Rays and Diagnostic Imaging - Out of Covered Auth is required for 2nd or more
Network spinal MRIs performed within a 12-
month period. Auth is required for
all PET scans.

Laboratory Outpatient and Professional $0 copay Auth is required for some genetic
Services - In Network testing codes

Laboratory Outpatient and Professional Covered Auth required. Auth is required for
Services - Out of Network some genetic testing codes

Mental Health and Substance Use Services

Assertive Community Treatment (ACT) - In Covered Auth required, Precert

Network

Assertive Community Treatment (ACT) - Out of Covered Auth required, Precert

Network

Intermediate Stay Unit (Second Chance Unit) - Covered NOA

In Network

Intermediate Stay Unit (Second Chance Unit) - Covered Auth Required, NOA
Out of Network

English (United States)

 Intensive Outpatient Program (IOP) BH - In Covered NOA
Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Intensive Outpatient Program (IOP) BH - Out of Covered Auth Required, NOA
Network

Intensive Outpatient Program (IOP) SUD - In Covered No Auth

Network

Intensive Outpatient Program (IOP) SUD - Out of Covered Auth required

Network

Personalized Recovery Oriented Services (PROS) Covered Precert after ISR; no auth required
- In Network effective 11/21/22

Personalized Recovery Oriented Services (PROS) Covered Auth required, precert after ISR
- Out of Network

Outpatient Psychotherapy - In Network Covered No Auth

Outpatient Psychotherapy - Out of Network Covered Auth requred

Comprehensive Psychiatric Emergency Program Covered No Auth

& Extended Observation - In Network

Residential Treatment Centers (RTC) Covered NOA

Rehabilitation - In Network

Residential Treatment Centers (RTC) Covered Auth Required, NOA

Rehabilitation - Out of Network

Crisis Intervention - In Network Covered NOA

Crisis Intervention - Out of Network Covered Auth required, NOA

Buprenorphine and Buprenorphine Covered No Auth

Management - In Network

Buprenorphine and Buprenorphine Covered Auth required

Management - Out of Network

Buprenorphine Prescribers - In Network Covered No Auth

Buprenorphine Prescribers - Out of Network Covered Auth required

Transcranial Magnetic Stimulation (TMS) - In Covered Precert

Network

Transcranial Magnetic Stimulation (TMS) - Out Covered Auth required, precert

of Network

English (United States)

 Gambling Disorder Treatment - In Network Covered No auth

Home (/Members/s/) My Benefit

Electroconvulsive Therapy (ECT)Plans (/Members/s/my-plans-home-page)
- In Network Covered My Claims (/Members/s/my-claims-home-page)
Precert

Electroconvulsive Therapy (ECT) - Out of Covered Auth required, precert

Network

Psych Testing - In Network Covered Precert

Psych Testing - Out of Network Covered Auth required, precert

Neuro Psych Testing - In Network Covered Precert

Neuro Psych Testing - Out of Network Covered Auth required, precert

Assistive Communicative Devices for Autism Covered Auth required

Spectrum Disorder (ASD) - In Network

Mental Health Inpatient Residential Treatment - Covered Auth required

In Network

Mental Health Inpatient Residential Treatment - Covered Auth required

Out of Network

Substance Use Detoxification - In Network Covered NOA

Comprehensive Psychiatric Emergency Program Covered Auth required

& Extended Observation - OON

Substance Use Detoxification - Out of Network Covered Auth required, NOA

Substance Use Rehabilitation - In Network Covered NOA

Substance Use Rehabilitation - Out of Network Covered Auth required, NOA

Gambling Disorder Treatment - Out of Network Covered Auth required

Residential Treatment Centers (RTC) Covered NOA

Stabilization - In Network

Crisis Intervention Benefit Crisis Residence Covered Auth required, NOA

Services - In Network

Residential Treatment Centers (RTC) Covered Auth Required, NOA

Stabilization - Out of Network

Crisis Intervention Benefit Crisis Residence Covered Auth required

Services - Out of Network

Mental/Behavioral Health Inpatient Services - In Covered Notice of Admission

Network
English (United States)
 Intensive Psychiatric Rehabilitation Treatment Covered Auth required
Program (IPRT) - In Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Intensive Psychiatric Rehabilitation Treatment Covered Auth required
Program (IPRT) - Out of Network

Screening, Brief Intervention and Referral to Covered No Auth

Treatment (SBIRT) - In Network

Screening, Brief Intervention and Referral to Covered No Auth

Treatment (SBIRT) - Out of Network

Mental/Behavioral Health Inpatient Services - Not Covered Auth required

Out of Network

Substance Use Disorder Inpatient Services - In Covered Auth required after NOA
Network

Substance Use Disorder Inpatient Services - Out Covered Auth required

of Network

Substance Use Disorder Outpatient Services - Covered Auth required

Out of Network

Substance Use Disorder Outpatient Services - In Covered Auth required after NOA
Network

Mental/Behavioral Health Outpatient Services - Covered No Auth

In Network

Mental/Behavioral Health Outpatient Services - Not Covered Auth required

Out of Network

Partial Hospitalization Services - In Network Covered Auth required after NOA

Partial Hospitalization Services - Out of Network Covered Auth required

Screening and Counseling to reduce alcohol Covered No Auth

misuse - In Network

Screening and Counseling to reduce alcohol Covered Auth required

misuse - Out of Network

Rehabilitative and Habilitative Services and Devices

Outpatient Rehabilitation Services - In Network $0 copay Effective 1/1/2023 Y-PT/OT after first
10 visits for each discipline.
Effective 1/1/2023 ST - Auth
Required

English (United States)

 Outpatient Rehabilitation Services - Out of Covered Effective 1/1/2023 Y-PT/OT after first
Network 10 visits for each discipline.
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) Effective
My Claims1/1/2023 ST - Auth
(/Members/s/my-claims-home-page)
Required

Habilitation Services - In Network Not Covered Not Covered

Habilitation Services - Out of Network Not Covered Not Covered

Chiropractic Care - In Network Covered Auth Required

Chiropractic Care - Out of Network Covered Auth Required

Durable Medical Equipment - In Network Covered Please contact Integra Health

Partners

Durable Medical Equipment - Out of Network Not covered Not Covered

Prosthetic Devices - In Network Covered Must contact Integra Health

Partners

Prosthetic Devices - Out of Network Covered Must contact Integra Health

Partners

Hearing Aids - In Network $0 copay Must contact Integra Health

Partners

Hearing Aids - Out of Network Covered Must contact Integra Health

Partners

Inpatient Rehabilitation Services - In Network Covered Auth Required; Auth required after
NOA for BH only

Cochlear Implants - In Network Covered Must contact Integra Health

Partners

Cochlear Implants - Out of Network Covered Must contact Integra Health

Partners

Pulmonary Rehabilitation Services - In Network Covered Auth required

Assistive Communication Devices - In Network Covered Auth Required

Pulmonary Rehabilitation Services - Out of Covered Auth required

Network

Assistive Communication Devices - Out of Covered Auth Required

Network

Supervised Exercise Therapy (SET) - In Network Not Covered Not Covered

English (United States)

 Supervised Exercise Therapy (SET) - Out of Not Covered Not Covered
Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Inpatient Rehabilitation Services - Out of Covered Auth required
Network

Rehabilitative Speech Therapy - In Network $0 copay Effective 1/1/2023 ST - Auth

Required; Children under 21 years

Rehabilitative Speech Therapy - Out of Network Covered Effective 1/1/2023 ST - Auth

Required; Children under 21 years

Rehabilitative Occupational and Rehabilitative $0 copay Effective 1/1/2023 Y-PT/OT after first
Physical Therapy - In Network 10 visits for each discipline. ;
Children under 21 years

Rehabilitative Occupational and Rehabilitative Covered Effective 1/1/2023 Y-PT/OT after first
Physical Therapy - Out of Network 10 visits for each discipline. ;
Children under 21 years

Cardiac Rehabilitation - In Network $0 copay Auth Required

Cardiac Rehabilitation - Out of Network Covered Auth Required

Other Services

Abdominal aortic aneurysm screening - In Not Covered Not Covered

Network

Autologous Blood Banking - Out of Network Covered Auth required

Bariatric Surgery - In Network Covered No auth

Bariatric Surgery - Out of Network Covered Auth required

Breast Reconstructive Surgery - In Network Covered Auth required for all elective
admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Breast Reconstructive Surgery - Out of Network Covered Auth required for all elective
admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Chemotherapy - In Network Covered Auth may be required for individual

drugs

Chemotherapy - Out of Network Covered Auth required. Auth may be

required for individual drugs

English (United States)

 Clinical Trials - In Network Covered Auth required

Home (/Members/s/) My Benefit

Abdominal aortic aneurysm Plans (/Members/s/my-plans-home-page)
screening - Out of Not Covered My
Not Claims (/Members/s/my-claims-home-page)
Covered
Network

Clinical Trials - Out of Network Covered Auth required

Diabetes Education - In Network $0 copay No Auth

Diabetes Education - Out of Network Covered Auth required

Diabetic Equipment and Supplies - In Network $0 copay No Auth

Diabetic Equipment and Supplies - Out of Covered Auth required

Network

Dialysis - In Network Covered No Auth

Dialysis - Out of Network Covered Auth required

Family Planning Services - In Network $0 copay Subject to copayments or

coinsurance

Family Planning Services - Out of Network Covered Auth required

Hospice Services - In Network Covered Auth required

Abortion - In Network Covered Auth required, Effective August 1,

2022 - no prior authorization
required from Plan or PCP for
abortion services. Authorization
required for non-participating
providers only

Hospice Services - Out of Network Covered Auth required

Infertility Treatment - In Network Covered Auth required

Infertility Treatment - Out of Network Covered Auth required

Infusion Therapy - In Network Covered Auth requried

Infusion Therapy - Out of Network Covered Auth required

Insulin Pump - In Network Covered Must contact Integra Health

Partners

Insulin Pump - Out of Network Not Covered Not Covered

Medical Nutrition Therapy - In Network Covered No Auth

English (United States)

 Medical Nutrition Therapy - Out of Network Covered Auth required

Medical Supplies - InMy

Home (/Members/s/) Network Covered
Benefit Plans (/Members/s/my-plans-home-page) Please contact(/Members/s/my-claims-home-page)
My Claims Integra Health
Partners

Abortion - Out of Network Covered Auth required, Effective August 1,

2022 - no prior authorization
required from Plan or PCP for
abortion services. Authorization
required for non-participating
providers only

Medical Supplies - Out of Network Not Covered Not Covered

Medically Necessary Abortions - In Network Covered Auth required

Medically Necessary Abortions - Out of Network Covered Auth required

Opioid Treatment Program Services - In Covered Auth required

Network

Opioid Treatment Program Services - Out of Covered Auth required

Network

Physician and Midwife Services for Delivery - In Covered No Auth

Network

Physician and Midwife Services for Delivery - Covered Auth required

Out of Network

Radiation - In Network $0 copay Auth for PET scans; Auth for spinal
MRI 2nd or more studies performed
within 12 month period

Radiation - Out of Network Covered Auth required

Reconstructive Surgery - In Network Covered Auth required for all elective

admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Acupuncture - In Network Not Covered Not Covered

Reconstructive Surgery - Out of Network Covered Auth required for all elective
admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Second Opinions on the Diagnosis of Cancer, Covered No Auth

Surgery and Other - In Network

English (United States)

 Second Opinions on the Diagnosis of Cancer, Covered Auth required
Surgery and Other - Out of Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Services to Treat Kidney Disease - In Network Covered No Auth

Services to Treat Kidney Disease - Out of Covered Auth required

Network

Sterilization Procedures for Men (Vasectomy) - $0 copay Subject to copayments or

In Network coinsurance

Sterilization Procedures for Men (Vasectomy) - Covered Auth required

Out of Network

Transplant - In Network Covered Auth required for all elective

admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Transplant - Out of Network Covered Auth required for all elective

admissions. Auth rules for
outpatient procedures are at the
CPT code level.

Treatment for Temporomandibular Joint $0 copay No Auth

Disorders - In Network

Acupuncture - Out of Network Not Covered Not Covered

Treatment for Temporomandibular Joint Covered Auth required

Disorders - Out of Network

Anesthesia Services - In Network Covered Auth required for all oral surgery
related anesthesia

Anesthesia Services - Out of Network Covered Auth required. Auth required for all
oral surgery related anesthesia

Autologous Blood Banking - In Network Covered No Auth

Prescription Drug Coverage

Generic Drugs - In Network $1 copay Authorization by CVS/Caremark is

required for Certain Classifications
of MedicationsOne copay for each
new prescription and each refill No
copay for: drugs to treat mental
illness (psychotropic) and
tuberculosis; contraceptive drugs or
devices; medicine t

English (United States)

 Generic Drugs - Out of Network Not Covered Not Covered

Mail Order - Enteral My

Home (/Members/s/) Formulas - Generic
Benefit Drugs - $0 copay
Plans (/Members/s/my-plans-home-page) Auth
MyRequired
Claims (/Members/s/my-claims-home-page)
In Network

Mail Order - Enteral Formulas - Generic Drugs - $1 copay Auth Required

Out of Network

Mail Order - Enteral Formulas - Non-Preferred $0 copay Auth Required

Brand Drugs - In Network

Mail Order - Enteral Formulas - Non-Preferred $1 copay Auth Required

Brand Drugs - Out of Network

Mail Order - Enteral Formulas - Preferred Brand $0 copay Auth Required

Drugs - In Network

Mail Order - Enteral Formulas - Preferred Brand $1 copay Auth Required

Drugs - Out of Network

Mail Order - up to a 30 day Supply - Generic $1 copay Authorization by CVS/Caremark is

Drugs - In Network required for Certain Classifications
of Medications

Mail Order - up to a 30 day Supply - Generic Not Covered Not Covered

Drugs - Out of Network

Mail Order - up to a 30 day Supply - Non- $3/$1 copay Authorization by CVS/Caremark is

Preferred Brand Drugs - In Network required for Certain Classifications
of Medications

Mail Order - up to a 30 day Supply - Non- Not Covered Not Covered

Preferred Brand Drugs - Out of Network

Preferred Brand Drugs - In Network $3 copay Authorization by CVS/Caremark is

required for Certain Classifications
of Medications. One copay for each
new prescription and each refill No
copay for: drugs to treat mental
illness (psychotropic) and
tuberculosis; contraceptive drugs or
devices; medicine

Mail Order - up to a 30 day Supply - Preferred $3/$1 copay Authorization by CVS/Caremark is

Brand Drugs - In Network required for Certain Classifications
of Medications

Mail Order - up to a 30 day Supply - Preferred Not Covered Not Covered

Brand Drugs - Out of Network

English (United States)

 Mail Order - up to a 90 day Supply - Generic $1 copay Authorization by CVS/Caremark is
Drugs - In Network required for Certain Classifications
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) of My
Medications
Claims (/Members/s/my-claims-home-page)

Mail Order - up to a 90 day Supply - Generic Not Covered Not Covered

Drugs - Out of Network

Mail Order - up to a 90 day Supply - Non- $3/$1 copay Authorization by CVS/Caremark is

Preferred Brand Drugs - In Network required for Certain Classifications
of Medications

Mail Order - up to a 90 day Supply - Non- Not Covered Not Covered

Preferred Brand Drugs - Out of Network

Mail Order - up to a 90 day Supply - Preferred $3/$1 copay Authorization by CVS/Caremark is

Brand Drugs - In Network required for Certain Classifications
of Medications

Mail Order - up to a 90 day Supply - Preferred Not Covered Not Covered

Brand Drugs - Out of Network

Prescription Drugs Administered in Outpatient $3/$1 Authorization by CVS/Caremark is

Facilities - In Network required for Certain Classifications
of Medications. Brand name: $3
copay; Generic: $1 copay

Prescription Drugs Administered in Outpatient Not Covered Not Covered

Facilities - Out of Network

Preferred Brand Drugs - Out of Network Not Covered Not Covered

Non-Preferred Brand Drugs - In Network $3 copay Authorization by CVS/Caremark is

required for Certain Classifications
of Medications. One copay for each
new prescription and each refill No
copay for: drugs to treat mental
illness (psychotropic) and
tuberculosis; contraceptive drugs or
devices; medicine

Non-Preferred Brand Drugs - Out of Network Not Covered Not Covered

Specialty Drugs - In Network $3 copay Authorization by CVS/Caremark is

required for Certain Classifications
of Medications. One copay for each
new prescription and each refill No
copay for: drugs to treat mental
illness (psychotropic) and
tuberculosis; contraceptive drugs or
devices; medicine

Specialty Drugs - Out of Network Not Covered Not Covered English (United States)
 Insulin (30-day Supply) - In Network $0 copay Must contact Integra Health
Partners
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)

Insulin (30-day Supply) - Out of Network Not Covered Not Covered

Pediatric Vision

Routine Eye Exam - Child - In Network Covered No Auth

Routine Eye Exam - Child - Out of Network Not Covered Not Covered

Eye Glasses - Child - In Network Covered No Auth

Eye Glasses - Child - Out of Network Not Covered Not Covered

Contact Lenses - Child - In Network Covered Auth required

Contact Lenses - Child - Out of Network Not Covered Not Covered

Pediatric Dental Care

Dental Checkup - Child - In Network Covered Must contact DentaQuest

Dental Checkup - Child - Out of Network Covered Must contact DentaQuest

Basic Dental Care - Child - In Network Covered Must contact DentaQuest

Basic Dental Care - Child - Out of Network Covered Must contact DentaQuest

Orthodontia - Child - In Network - In Network Covered Must contact DentaQuest

Orthodontia - Child - Out of Network - Out of Covered Must contact DentaQuest

Network

Major Dental Care - Child - In Network Covered Must contact DentaQuest

Major Dental Care - Child - Out of Network Covered Must contact DentaQuest

Adult Dental Care

Major Dental Care - In Network Covered Must contact DentaQuest

Major Dental Care - Out of Network Covered Must contact DentaQuest

Orthodontia - In Network $0 copay Must contact DentaQuest

Orthodontia - Out of Network Covered Must contact DentaQuest

Routine Dental Care - In Network Covered Auth required for anesthesia for
ambulatory oral surgery and for
English (United States)
 elective admissions for oral surgery
and must be obtained from the
MetroPlus UM Department
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)

Routine Dental Care - Out of Network Covered Auth required for anesthesia for
ambulatory oral surgery and for
elective admissions for oral surgery
and must be obtained from the
MetroPlus UM Department

Basic Dental Care - In Network Covered Must contact DentaQuest

Basic Dental Care - Out of Network Covered Must contact DentaQuest

Dental Services - Endodontics - In Network Covered Must contact DentaQuest

Dental Services - Endodontics - Out of Network Covered Must contact DentaQuest

Dental Services - Periodontics - In Network Covered Limited, must contact dental

vendor

Dental Services - Periodontics - Out of Network Covered Limited, must contact dental
vendor

Dental Services - Restorative and Covered Must contact DentaQuest

Prosthodontics - In Network

Dental Services - Restorative and Covered Must contact DentaQuest

Prosthodontics - Out of Network

Adult Vision

Routine Eye Exam - Adults - In Network Covered No Auth

Routine Eye Exam - Adults - Out of Network Not Covered Not Covered

Vision Care (Adult Eyewear) - In Network Covered No Auth

Vision Care (Adult Eyewear) - Out of Network Covered Auth required

Supplemental Benefits

Post Discharge Meals - In Network Not Covered Not Covered

Post Discharge Meals - Out of Network Not Covered Not Covered

Additional Medical Benefits

Counseling to stop smoking or tobacco use - In Covered No auth

Network

English (United States)

 Counseling to stop smoking or tobacco use - Covered Auth required
Out of Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Remote Patient Monitoring (RPM) for Maternal Covered No Auth
Care via Telehealth - In Network

Personal Care Services (PCS) - In Network Covered Auth required

Personal Care Services (PCS) - Out ofNetwork Covered Auth required

Consumer-Directed Personal Assistance Covered Auth required

Services (CDPAS) - In Network

Consumer-Directed Personal Assistance Covered Auth required

Services (CDPAS) - Out of Network

Adult Day Health-Care - In Network Covered Auth required

Adult Day Health-Care - Out of Network Covered Auth required

AIDS Adult Day Health-Care - In Network Covered Auth required

AIDS Adult Day Health-Care - Out of Network Covered Auth required

Asthma Self Management Training - In Network Covered No Auth

Post Discharge Meals - In Network Not Covered Not Covered

Asthma Self Management Training - Out of Covered Auth required

Network

Automatic External Defibrillator - In Network Covered Please contact Integra Health

Partners

Automatic External Defibrillator - Out of Covered Please contact Integra Health

Network Partners

BRCA Risk Assessment and Genetic Testing and Covered Auth required for BRCA testing
Counseling - In Network

BRCA Risk Assessment and Genetic Testing and Covered Auth required for BRCA testing
Counseling - Out of Network

Capsule Endoscopy Camera Pill - In Network Covered Auth required

Capsule Endoscopy Camera Pill - Out of Covered Auth required

Network

Cardio MEMS Champion Heart Failure Covered Auth required

Monitoring - In Network

English (United States)

 Cardio MEMS Champion Heart Failure Covered Auth required
Monitoring - Out of Network
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
Cosmetic Surgery - In Network Covered Auth required

Post Discharge Meals - Out of Network Not Covered Not Covered

Cosmetic Surgery - Out of Network Covered Auth required

End of Life Acute Care - In Network Covered Auth required for all elective
admissions

End of Life Acute Care - Out of Network Covered Auth required for all elective
admissions

Exchange Transfusion for Sickle Cell Disease - In Covered Auth required

Network

Exchange Transfusion for Sickle Cell Disease - Covered Auth required

Out of Network

Foot Care Services - In Network Covered No auth, The authorization rules for
outpatient procedures are at the
CPT code level.

Foot Care Services - Out of Network Covered Auth required, The authorization
rules for outpatient procedures are
at the CPT code level.

Gender Dysphoria Services - In Network Covered Auth required

Gender Dysphoria Services - Out of Network Covered Auth required

Gender Reassignment Surgery - In Network Covered Auth required

Telehealth - In Network Covered Auth Required

Gender Reassignment Surgery - Out of Network Covered Auth required

Hospital Admissions for Acute Care - In Network Covered Auth required for all emergent and
elective admissions

Hospital Admissions for Acute Care - Out of Covered Auth required for all emergent and
Network elective admissions

Hospital Admissions for Maternity Care - In Covered Authorization is required for

Network elective admissions for pre-planned
caesarean section deliveries.
Authorization is not required for
emergency admissions for

English (United States)

 spontaneous labor deliveries
(vaginal and c-section)

Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)

Hospital Admissions for Maternity Care - Out of Covered Authorization is required for
Network elective admissions for pre-planned
caesarean section deliveries.
Authorization is not required for
emergency admissions for
spontaneous labor deliveries
(vaginal and c-section)

Maternal Depression Screening - In Network Covered No auth

Maternal Depression Screening - Out of Covered Auth required

Network

Long Term Health Care Program (LTHHCP) Covered Auth required

Services - In Network

Long Term Health Care Program (LTHHCP) Covered Auth required

Services - Out of Network

Magnetic Resonance Guided Focused Covered Auth required

Ultrasound - In Network

Telehealth - Out of Network Covered Auth Required

Magnetic Resonance Guided Focused Covered Auth required

Ultrasound - Out of Network

Maternity and Newborn Care - Outpatient - In Covered No auth

Network

Maternity and Newborn Care - Outpatient - Out Covered Auth required

of Network

Personal Emergency Response System (PERS) - Covered Auth required

In Network

Personal Emergency Response System (PERS) - Covered Auth required

Out of Network

Residential Health Care Facility or Long Term Covered Auth required

Care Services - Out of Network

Medical Supplies - In Network Covered Auth required

Developmental Screening - In Network Covered No auth

Medical Supplies - Out of Network Covered Auth required

Developmental Screening - Out of Network Covered Auth required English (United States)
 Transportation (Routine/Non-Emergent) - In Covered by Medicaid Fee for Must contact Medical Answering
Network Service Services
Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)

National Diabetes Prevention Program (NDPP) - Covered No auth

In Network

National Diabetes Prevention Program (NDPP) - Covered Auth required

Out of Network

Nerve Conduction Studies (NCS) - In Network Covered Auth required

Nerve Conduction Studies (NCS) - Out of Covered Auth required

Network

Oral Surgery - In Network Covered No auth

Oral Surgery - Out of Network Covered Auth required

Pasteurized Human Donor Milk (PHDM) - In Covered Auth required

Network

Pasteurized Human Donor Milk (PHDM) - Out of Covered Auth required

Network

Polysomnography and Sleep Studies - In Covered Auth required

Network

Polysomnography and Sleep Studies - Out of Covered Auth required

Network

Transportation (Routine/Non-Emergent) - Out Covered by Medicaid Fee for Must contact Medical Answering
of Network Service Services

PrEP HIV Prevention - In Network Covered No auth

PrEP HIV Prevention - Out of Network Covered Auth required

Lung Cancer Screening - In Network Covered Auth required

Lung Cancer Screening - Out of Network Covered Auth required

Prostate Cancer Screening - In Network Covered No auth

Prostate Cancer Screening - Out of Network Covered Auth required

Topical Oxygen Therapy - In Network Covered Auth required

Topical Oxygen Therapy - Out of Network Covered Auth required

Urine Drug Testing - In Network Covered Auth required

English (United States)
 Urine Drug Testing - Out of Network Covered Auth required

Home (/Members/s/) My Benefit

Remote Patient Monitoring Plans
(RPM) (/Members/s/my-plans-home-page)
via Telehealth Covered NoMy Claims (/Members/s/my-claims-home-page)
Auth
- In Network

Video Electroencephalographic Monitoring Covered Auth required

(VEEG) - In Network

Video Electroencephalographic Monitoring Covered Auth required

(VEEG) - Out of Network

Remote Patient Monitoring (RPM) via Telehealth Covered Auth required

- Out of Network

Over the Counter (OTC) Items $0.50 copay Authorization by CVS/Caremark is

required for Certain Classifications
of Medications

VFCA Foster Care

Core Limited Health-Related Services - In Covered No auth

Network

Core Limited Health-Related Services - Out of Covered Auth required

Network

Visit Us

English (United States)

Home (/Members/s/) My Benefit Plans (/Members/s/my-plans-home-page) My Claims (/Members/s/my-claims-home-page)
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