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  • Covered Services

    PHC California covers the following services with no copays or deductibles. Limitations and rules on how to get care are below. More detailed information is in the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2023). Look in Section 4, Benefits and Services. If you have questions about covered services, please contact Member Services.

    Services ProvidedLimitations
    AcupuncturePHC California covers acupuncture services to prevent, modify or alleviate the perception of severe, persistent chronic pain resulting from a generally recognized medical condition. Outpatient acupuncture services (with or without electric stimulation of the needles) are covered; limited to two (2) services per month, in combination with audiology, chiropractic, occupational therapy and speech therapy services; requires prior authorization
    Alcohol Abuse TreatmentAvailable through the Drug Medi-Cal Program. PHC California will refer members to Los Angeles County Public Health Substance Abuse Prevention and Control Program for such services if necessary. (By clicking on the link above, you will be taken to a website operated by Los Angeles County Public Health and not PHC California.)
    Allergy CarePHC California covers allergy testing and treatment, including allergy desensitization, hyposensitization, or immunotherapy when medically necessary; no limits; certain services require prior authorization
    Ambulance ServicesFor emergencies; covered when medically necessary; no limits
    Anesthesiologist ServicesCovered when medically necessary; no limits; requires prior authorization
    Audiology ServicesCovered when medically necessary; limited to two (2) services per month, in combination with acupuncture, chiropractic, occupational therapy and speech therapy services; requires prior authorization
    Behavioral Health TreatmentsBehavioral health treatment includes services and treatment programs, such as applied behavior analysis and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual; covered when medically necessary; requires prior authorization
    Cancer Clinical TrialsPHC California covers a clinical trial if it is related to the prevention, detection or treatment of cancer or other life-threatening conditions and if the study is conducted by the U.S. Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC) or Centers for Medicare and Medicaid Services (CMS). Studies must be approved by the National Institutes of Health, the FDA, the Department of Defense or the Veterans Administration.
    Case Management and Disease Management ServicesCovered; no limits
    Certified Nurse Practitioner/Physician Assistant ServicesCovered when medically necessary; no limits; certain services require prior authorization
    Chemotherapy and Radiation TherapyCovered; no limits; requires prior authorization
    Chiropractic ServicesCovered when medically necessary; limited to two (2) services per month in combination with acupuncture, audiology, occupational therapy and speech therapy services; limited to the treatment of the spine by means of manual manipulation; procedures require prior authorization
    Clinical Services from Federally Qualified Health Care Centers (FQHCs) and Indian Health ClinicsPrimary care and preventive physician services covered; limit of one (1) visit per day
    Clinical Services from Los Angeles County Health Services ClinicsPrimary care and preventive physician services covered; limit of one (1) visit per day
    Clinical Services from Rural Health Clinics (RHCs)Primary care, preventive physician and laboratory services covered; limit of one (1) visit per day; certain laboratory services require prior authorization
    Dermatology ServicesCovered when medically necessary; no limits; certain services require prior authorization
    Dialysis Services (hospital-based and free standing)Covered when medically necessary; no limits; requires prior authorization
    Durable Medical EquipmentCovered when medically necessary; requires prior authorization
    Emergency Room ServicesCovered when medically necessary; no limits
    Enteral and Parenteral NutritionThese methods of delivering nutrition to the body are used when a medical condition prevents you from eating food normally. Covered when medically necessary; no limits; requires prior authorization
    Family Planning ServicesCovered; no limits. Available through any participating Medi-Cal provider.
    Hearing AidsPHC California covers hearing aids if you are tested for hearing loss and have a prescription from your doctor; requires prior authorization
    Home Health Care ServicesCovered when medically necessary; no limits; requires prior authorization
    Hospice CareCovered for terminally ill members who have a life expectancy of six months or less; requires prior authorization.
    ImmunizationsCovered; no limits
    Inpatient Hospital Services, including Anesthesiologist and Surgical ServicesCovered when medically necessary; no co-pay; requires prior authorization.
    Investigational ServicesCovered when conventional therapies will not adequately treat condition or prevent disability or death; no limits; requires prior authorization
    Laboratory/X-Ray/Imaging ServicesCovered when medically necessary; no limits; certain services require prior authorization
    Long-Term CareCovered when medically necessary; no limits; requires prior authorization

    Maternity Services, including:

    • Delivery and postpartum care
    • Prenatal care
    • Diagnosis of fetal genetic disorders and counseling
    Covered when medically necessary; no limits; certain services require prior authorization
    Medical Supplies, Equipment and AppliancesCovered when medically necessary; no limits; requires prior authorization
    Medical/Drug Treatment TherapiesCovered when medically necessary; no limits; requires prior authorization
    Mental Health Services

    PHC California covers an initial mental health assessment without requiring prior authorization. You may get a mental health assessment at any time from a licensed mental health provider in the PHC California network without a referral. Your PCP or mental health provider will make a referral for additional mental health screening to a specialist within the PHC California network to determine your level of impairment. If your mental health screening results determine you are in mild or moderate distress or have impairment of mental, emotional or behavioral functioning, PHC California can provide mental health services for you through its mental health provider network.

    Specialty mental health services and inpatient psychiatric services available through the Los Angeles County Department of Mental Health. (By clicking on the link above, you will be taken to a website operated by the Los Angeles County Department of Mental Health and not PHC California.) PHC California will refer you for such services if you need them.

    Medical/Drug Treatment TherapiesCovered when medically necessary; no limits; requires prior authorization
    Occupational TherapyPHC California covers occupational therapy services, including occupational therapy evaluation, treatment planning, treatment, instruction and consultative services when medically necessary; limited to two (2) services per month, in combination with acupuncture, audiology, chiropractic and speech therapy services; requires prior authorization
    Ophthalmology ServicesCovered when medically necessary; no limits; requires prior authorization
    Ostomy and Urological SuppliesPHC California covers ostomy bags, urinary catheters, draining bags, irrigation supplies and adhesives when medically necessary; no limits; requires prior authorization
    Outpatient Hospital ServicesCovered when medically necessary; no limits; requires prior authorization
    Outpatient SurgeryCovered when medically necessary; no limits; requires prior authorization
    Optometric and Vision ServicesRoutine eye exams and prescriptions for eye glasses/corrective lenses covered. No limits. Eyeglasses are covered for members once every 24 months; contact lens when required for medical conditions such as aphakia, aniridia and keratoconus.

    Outpatient Rehabilitation Services

    • Cardiac Rehabilitation
    • Pulmonary Rehabilitation
    Covered when medically necessary; no limits; requires prior authorization
    Palliative CareCovered; requires prior authorization
    Physical TherapyCovered when medically necessary; no limits; requires prior authorization
    Physician Primary Care ServicesCovered; limited to one (1) visit per day
    Physician Specialty Care ServicesCovered when medically necessary; limited to one (1) visit per day per specialist; referral required; procedures require prior authorization
    Podiatry ServicesCovered when medically necessary; no limits; certain services require prior authorization
    Prescription DrugsCovered when medically necessary; no limits; prior authorization required on certain drugs; quantity limits on certain drugs
    Prosthetic and Orthotic AppliancesCovered when medically necessary; no limits; requires prior authorization
    Reconstructive ServicesPHC California covers surgery to correct or repair abnormal structures of the body to improve or create a normal appearance to the extent possible. Abnormal structures of the body are those caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. No limits; requires prior authorization.
    Sexually Transmitted Disease (STD) Testing, Counseling and TreatmentCovered; no limits; available through any participating Medi-Cal provider
    Skilled Nursing Facility ServicesCovered when medically necessary; no limits; requires prior authorization
    Speech TherapyCovered when medically necessary; limited to two (2) services per month in combination with acupuncture, audiology, chiropractic and occupational therapy; requires prior authorization
    Substance Abuse TreatmentAvailable through the Drug Medi-Cal Program. PHC California will refer members to Los Angeles County Public Health Substance Abuse Prevention and Control Program for such services if necessary. (By clicking on the link above, you will be taken to a website operated by Los Angeles County Public Health and not PHC California.)
    Transgender ServicesPHC California covers transgender services (gender-affirming services) as a benefit when they are medically necessary or when the services meet the criteria for reconstructive surgery. Requires prior authorization.
    Transplant ServicesKidney transplant covered when medically necessary; no limits; requires prior authorization. Other major organ transplants covered under Regular Medi-Cal (fee for service) and require disenrollment from the plan.
    Transportation (Non-Emergency)Covered; no limits; plan must arrange transportation to and from plan-approved locations
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    The benefit information provided is a brief summary, not a complete description of benefits. Limitations and restrictions apply. Benefits, formulary, and/or pharmacy network may change.

     

    DHCS 030716 PHC FR Form 1.0