Benefits overview

Expanded benefits

Benefit Details
Service Benefit OK from Doctor Needed
Dental – adults  
  • Maximum $1500 benefit
  • Preventive services – one cleaning and oral exam every six months
  • One x-ray per year
  • One fluoride treatment per year
  • Treatment for periodontal disease
 Yes - for treatment of periodontal disease
Intensive Outpatient Therapy for Substance Abuse 
  • No limits when medically necessary

Yes

Nutritional Counseling 
  • Up to 15 visits per year when medically necessary

Yes

OB Visits
  • 10-14 visits for routine pregnancy care
  • No limit for high-risk pregnancy care
  • One home visit after delivery

No

Outpatient Hospital
Services
  • Not limited to $1500 based on medical necessity and in lieu of hospital admission

Yes

Over the Counter Medication/Supplies 
  • Magellan Complete Care covers certain over the counter items. The limit of your benefit is $25 a month per household.

No prescription required

Post discharge meals
  • Post discharge from inpatient admission; Three home delivered meals for up to two days for member and up to three family members; requires 48 hours notice by member when medically  necessary

Yes

Primary Care Visits – enhanced for non-pregnant adults 
  • One per day
  • Not limited to two per month

No

Vaccine – adult pneumonia 
  •  One per lifetime as medically advised
 No
Vaccine - adult influenza
  • One per year as medically advised for members 19 and over

No

Vaccine - adult shingles
  • One per lifetime as medically advised

No

Vision Services - adult
  • Routine eye exam and glasses once every 12 months
  • Additional exams and glasses with OK from doctor
  • For specialty glasses (new wearers, historic, RGP, multi-focal, etc.), the enrollee must pay for any charges over $50, less a 20 percent discount 

Yes – for services beyond the annual benefit

Co-pays
  • Waived
Yes
Home Health Visits -- non pregnant adults
  • Unlimited when medically necessary
Yes

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