Molinalogo

• Require Prior Authorization

Including MYPAC, inpatient/outpatient care, psychiatric residential treatment facilities and therapeutic and evaluative services
All Medicaid policy restrictions apply

For members with a chronic disease – disease management

$700 maximum per year for members 21 and over. Members under 21 can get additional services if medically necessary and prior authorization is obtained

Limitations may apply based on type of services provided.
All Medicaid policy restrictions apply

Dental

- Emergency pain relief
- Palliative care

$2,500 maximum per year

Dental

- Preventive
- Diagnostic
- Restorative
$2,500 maximum per year

Orthodontia

$4,620 maximum per lifetime per child

Annually

Freestanding or hospital-based center services

All Medicaid policy restrictions apply.

Limited to beneficiaries under 21 years of age.

No Limit

Adults: 1 eye exam and 1 pair of glasses every fiscal year

Children: (under age 21) 2 eye exams per year and 2 pair of glasses. EPSDT- eligible members are eligible for more services if determined medically necessary.

Inheritable disease diagnosis such as Sickle Cell

Hearing aids are covered for members under 21 years of age, including cochlear implants

Limited to 36 visits per year. Members under 21 can get additional visits if authorized. Physical therapy and speech therapy visits in the home health setting are not covered through the home health program for beneficiaries age 21 and over.

Inpatient and Outpatient

Inpatient and Outpatient

Requires consent form with authorization request

All Medicaid policy restrictions apply.

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

24-hour nurse advice line: (844) 794-3638

Including Prenatal/Postpartum visits

Inpatient/outpatient setting

All Medicaid policy restrictions apply.

24/7 Personal Care Managers available in clinics

No limit

Subject to qualifying systemic diagnosis

Including postpartum care

6 per month; EPSDT eligible 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, EPSDT services

Physician's Office or Outpatient department of a hospital

Infusion in home setting applies to home health benefit limits

Covered for members 21 and over

Requires properly signed consent form, see Title 23: Medicaid Part 202, Rule 5.3 for more information

Limitations may apply based on type of services provided. Prior authorization may be required.

Limited to beneficiaries under 21

Outpatient

Yes, in accordance with Title 23: Medicaid Part 202, Rule 4.2 and 4.3

EPSDT immunizations, flu shots and pneumonia vaccines