Molinalogo

• Behavioral health (refer to the covered behavioral health services for all members section below for more details)
• Breast reconstruction after mastectomy
• Chemotherapy and radiation
• Circumcisions, when medically necessary (prior authorization required)
• Diabetes testing and testing supplies
• Cardiac (heart) and pulmonary (breathing) rehabilitation
• Dialysis
• Durable medical equipment (DME) and supplies
• Emergency care (includes care to stabilize you after an emergency)
• Emergency dental care
  • Limited to $1,000 per year
• Emergency and non-emergency transportation
• End of life care
• Family planning services
  • Birth control
  • Contraceptives
  • Family planning counseling
• Hearing loss evaluation
• High tech radiology, including:
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiogram (MRA)
  • Positron emission tomography (PET scan)
• HIV/AIDS therapy and counseling services
• Home health care
• Hospital services
  • Inpatient
  • Outpatient
• Immunizations (shots)
• Incontinence briefs (for members over 21 years of age, when needed)
• Inpatient hospital stays may include:
  • Physical therapy
  • Occupational therapy
  • Speech therapy
• Laboratory, x-rays, medical imaging
• Maternity care
• Medical equipment and supplies
• Medical foods
• Nursing facility stay
  • Limited to 90 calendar days per year
• Nutritional assessments and medical foods
• Occupational therapy
• Orthotics and prosthetics
• Out-of-network services
• Pain management services
• Physical therapy
• Podiatry (foot and ankle)
• Pregnancy care
• Prescription medications and injections
• Primary care provider (PCP) office visits, including:
  • Wellness exams
  • Preventive care
• Preventive screenings and tests:
  • Pap tests
  • Mammogram
  • Colonoscopy
• Rehabilitation therapy
• Respirational therapy
• Specialist office visits
• Second opinions
• Surgery
• Smoking cessation
• Transplants that are approved by AHCCCS (organ and tissue)
• Urgent care

All members also get well visits as part of their covered services. As part of your wellness visit, you get services, but not limited to, well woman exams, breast exams and prostate exams for members 21 years and older. These also include a medical history, physical exam, health screening, health counseling and any medically necessary shots.

In addition to the covered services for all members, members under 21 years of age get the following benefits:

• Chiropractic care (when medically necessary)
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) includes:
  • Wellness exams
  • Hearing exams and hearing aids
  • Preventive dental care
  • Orthotics covered for AHCCCS members under 21 years of age
• Dental screenings and treatments
• Glasses
• Outpatient physical, occupational and speech therapy
• Personal care services that are necessary to meet a medical need. This includes help with:
  • Activities of daily care
  • Bathing
  • Toileting
  • Walking
• Vision exams

Some services have specific limits:

• Behavioral health services
  • See section below on covered behavioral health services
• Home-and community-based services
  • Members should use the home-and community-based services instead of a nursing home when medically able
• Nursing home
  • Up to 90 days per contract year (contract year is from October 1-September 30)
• Personal care items
  • Only covered when used to treat a medical condition
• Vision care
  • Limited to medical eye conditions
  • Eye exams and glasses covered for children under 21 years of age
  • Eyeglasses covered for adults after undergoing cataract surgery
• Orthotic devices
  • MCC only covers orthotic devices when all three below are met:
    • The orthotic is medically necessary
    • The orthotic costs less than all other treatments and surgery to treat the same conditions
    • The orthotic is ordered by a doctor or primary care practitioner (nurse practitioner or physician assistant)

• Behavioral health counseling and therapy:
  • Individual
  • Group and family
• Screening, evaluation, assessment and testing
• Substance use services:
  • Intensive outpatient
  • Residential
  • Inpatient
• Multisystemic therapy (for members under 21 years of age)
• Auricular acupuncture (a type of acupuncture that involves inserting needles into specific points on the ear) *
• Skills, trainings and development and psychosocial rehabilitation living skills training
• Behavioral health prevention/promotion education and medication training
• Help and training to maintain employment
• Laboratory, radiology and medical imaging
• Medical management
• Electroconvulsive therapy
• Care management
• Personal care services
• Home care training and family support
• Self-help and peer services
• Home care training for home care client
• Unskilled respite care
• Wraparound services to maintain supportive housing
• Behavioral health respite care
  • Limited to 600 hours per year, October 1-September 30 (contract year)
• Sign language or oral interpretative services provided at no cost to the member
• Emergency and non-emergency transportation
• Crisis intervention:
  • Mobile, community-based
  • Stabilization, facility-based
  • Over the phone via crisis line
• Hospital
• Subacute facility
• Residential treatment center
• Behavioral health residential facility (without room and board*)
• Supervised behavioral health services and day programs
• Community psychiatric supportive treatment and adult behavioral health therapeutic homes

*Services not available with Title XIX/XXI funding but may be provided if other funds are available

MCC members get prescription drugs and other pharmacy benefits from the plan with no copays or deductibles. Your drugs are covered when you show your member ID card at a network pharmacy when you get your prescriptions filled.

We use MagellanRx to administer your pharmacy benefits. Visit the MagellanRx website to:

• Order refills for existing and unexpired mail-order prescriptions
• Learn about potential drug-to-drug interactions
• Understand your drugs common side effects or significant risks
• Find out the availability of generic substitutions
• Find the location of an in-network pharmacy based on a proximity search by ZIP code
• Find out if a medicine has been recalled

MCC Searchable Drug List

You may qualify to have your regular medicine mailed to you. To get started:

1. Call Member Services at (800) 424-5891 (TTY/TDD: 711)
2. Talk with the representative and check if your medicine qualifies for this service
3. Complete the request and your medicine will be mailed to you

You may also talk to you doctor if you have more questions about mail order services.

MCC covers a comprehensive list of drugs chosen for their effectiveness by MCC and a team of doctors and pharmacists. This drug list, called a formulary, lists brand name and prescription drugs and lists any rules or restrictions that apply. We also cover many over-the-counter (OTC) medications when you have a prescription from your doctor. Visit the MCC Searchable Drug List to review the formulary.

You pay nothing for covered prescription medications. MCC members have no annual deductible, no copays and no premiums.

Use the provider search tool to search for a network pharmacy near you. Our network includes many types of pharmacies and drugstores, including mail-order and specialty pharmacies.

There are two (2) ways to find your drug in the formulary:

• Search by medical condition:

Drugs are grouped by the medical conditions they are used to treat. If you know what the drug is used for, look for the category name, then the drug name. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Medications.

• Search by drug name:

Use the index at the back of the book to search by drug name. Drugs in the index are listed alphabetically. Then, go to the page number listed beside the drug name to get information about the drug.

When you find your drug, any rules or special requirements are listed under the column titled Requirements/Limits. There are generally three (3) types of requirements your drug may have:

• Prior Authorization: indicated by PA in the Requirements/Limits column
• Quantity Limits: indicated by QL in the Requirements/Limits column
• Step Therapy: indicated by ST in the Requirements/Limits column

For medical exceptions, please have your provider call Member Services at (800) 424-5891 (TTY/TDD: 711). We’re available Monday-Friday 8 am-6 pm.

For certain drugs, you or your provider need to get preapproval (or prior authorization) from MCC before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

Learn how to request prior authorization from MCC.

Download the prior authorization form based on the type of prescription you need:

• Prior authorization request form (Coming Soon)
• Prescription drug prior authorization request form (Coming Soon)
• Specialty medication prior authorization request form (Coming Soon)
• MCC Clinical Criteria Guide

MCC limits the amount of certain types of medication you can receive in a certain time period. We do this to help ensure safe, cost-effective use of these drugs. For example, if it’s considered safe to take only one pill per day of a drug, we may limit the quantity you’re able to receive to 30 pills in a 30-day period.

In some cases, we require that you first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat the condition but Drug A costs less, you may need to try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B. Your provider can learn more about how we determine whether step therapy is needed here.

There may be times when you need a drug that’s not on our formulary or that is on our formulary but has restrictions. When this happens, you can:

• Talk to your doctor to decide if you should switch to another drug on our formulary.
• Ask your doctor to request a formulary exception.
• In some situations, get a temporary supply of the drug.

In certain situations, we can provide a temporary supply of your drug. This applies to:

• New MCC members within the first 90 days of membership
• Current members affected by annual formulary changes during the first 90 days of the new year
• You may request a formulary exception in advance for the following year

During the transition period, we will automatically process a 30-day supply refill of your drug. Quantity may be less if your prescription is written for less than a 30-day supply. Once we cover the temporary supply, we generally won’t cover the drug again under our transition policy. You’ll receive a written notice explaining the steps you can take to request an exception or to work with your doctor on finding another drug on our formulary.

For new members residing in long-term care facilities, we’ll cover more than one refill during the first 90 days of membership. If you’ve been enrolled for more than 90 days, we’ll cover a temporary 31-day emergency supply (unless the prescription is for fewer days) while you’re pursuing the formulary exception.