Molinalogo

• Require Prior Authorization

Including inpatient/ outpatient care, psychiatric residential treatment facilities and therapeutic and evaluative services

For members with a chronic disease – disease management

$2,000 maximum

Limitations may apply based on type of services provided.

Dental

- Preventive
- Diagnostic
- Restorative
- Orthodontia
$2,000 maximum per year 

Annually

Freestanding or hospital-based center services

Prior Authorization Required

Unlimited

No Limit

1 eye exam and 1 pair of glasses every year

Inheritable disease diagnosis

Hearing aids are covered for members, including cochlear implants 

Limited to 36 visits per year. Home Health services must be approved.

Inpatient and Outpatient

Inpatient and Outpatient

Requires consent form with authorization request

Prior Authorization Required

To medical appointments, vision exams and pharmacy visits immediately following a medical appointment 

Including but not limited to Thallium stress test or nuclear stress test

Including Prenatal visits

Inpatient/outpatient setting

Prior Authorization Required

No limit

Subject to qualifying systemic diagnosis

Notification of pregnancy required as soon as possible 

6 per month; Members are eligible for more prescriptions if determined to be medically necessary. 72-hour supply of emergency drugs.

Mammograms, well baby and well child care, regular check-ups.

Physician's Office or Outpatient department of a hospital

Infusion in home setting applies to home health benefit limits

Inpatient/Outpatient care

Limited to beneficiaries under 21

Outpatient

Prior Authorization Required

EPSDT immunizations, flu shots and pneumonia vaccines

For ages 0-19