IEHP - 2024 Plan Benefits (2024)

• Doctor Visit: $0
• Vision care:a combined limit of $350 each yearfor contact lenses and/or eyeglasses (frames and lenses)
• Contact Lenses are covered up to $350 every twelve months in lieu of eyeglasses (Lenses and Frames).
• Inpatient Hospital Care: $0
• Home Health Agency Care: $0
• Ambulance Services: $0
• Transportation: $0. Including bus pass. Call our transportation vendor Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST).Call at least 5 days before your appointment.
• Diagnostic Tests, X-Rays & Lab Services: $0
• Durable Medical Equipment: $0
• Home and Community Based Services (HCBS): $0
• Community Based Adult Services (CBAS): $0
• Long Term Care that includes custodial care and facility: $0
• Utilities allowance of $65 for covered utilities. You must qualify for this benefit.
• Over the Counter (OTC) items allowance of $40 per quarter (every 3 months) towards the purchase of certain Over the Counter (OTC) items.

With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.

• Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.

After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to theIEHP DualChoice Member Handbook, updated 09/20/23

• 2024 Summary of Benefits (PDF)
• 2024 Annual Notice of Changes (PDF)
• 2024 IEHP DualChoice Member Handbook (PDF), updated 10/13/23

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files.Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:

• 1-800-MEDICARE (1-800-633-4227)., TTY users should call (877) 486-2048, 24 hours a day/7days a week
• The Social Security Office at (800) 772-1213 between 8 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
• Your State Medicaid Office

Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.

To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8 a.m. -8 p.m. (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.

What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).

• Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
• Flu shots as long as you get them from a network provider.
• Emergency services from network providers or from out-of-network providers.
• Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)

A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

• Oncologists care for patients with cancer.
• Cardiologists care for patients with heart conditions.
• Orthopedists care for patients with certain bone, joint, or muscle conditions.

You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.

When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.