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Ambulance
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Not covered
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N/A
|
|
Case Management
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GHP care managers help members receive the care, education and support they need to manage their diseases.
|
N/A
|
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Chiropractor
|
Not covered
|
N/A
|
|
Dental
|
Not covered
|
N/A
|
|
Diabetic Education
|
Specific code ranges covered if ordered by an MD, DO, or NP.
|
N/A
|
|
Emergency Department
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Not covered
|
N/A
|
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Eyeglasses
|
Not covered
|
N/A
|
|
Family Planning
- Infertility screening
- Contraceptive devices
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Not covered. May go to a local designated Family Planning Program
|
N/A
|
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Hearing Aids
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Not covered
|
N/A
|
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Home Health
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Not covered
|
N/A
|
|
Home Help (personal care)
|
Not covered
|
N/A
|
|
Hospice
|
Not covered
|
N/A
|
|
Inpatient Hospital
|
Not covered
|
N/A
|
|
Lab & X-ray
|
Covered if ordered by an MD, DO, or NP in a freestanding facility.
Not covered in any setting: nuclear radiology (includes tests like PET and radioisotope related procedures).
|
Radiology: $5 coapy
Lab: N/A
|
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Medical Supplies/Durable Medical Equipment (DME)
|
Limited coverage. Medical supplies are covered except for the following categories:
- Gradient surgical garments, formulas and feeding supplies, and supplies related to any DME item not covered.
- DME items are Not covered except for glucose monitors.
|
No copays for diabetic supplies
|
|
Mental Health Services
|
May be covered through local community mental health centers.
|
N/A
|
|
Nursing Facility
|
Not covered
|
N/A
|
|
Optometrist
|
Not covered
|
N/A
|
|
Outpatient Hospital (Not emergency department)
|
Covered:
- Services performed by a radiologist. Both facility and professional services are covered. Care Core reviews services as appropriate .
- Professional services.
- Wound therapy services.
- Physical, Occupational & Speech Therapy evaluation only.
- Hospitals will receive reimbursement for covered outpatient surgeries (other than services performed by a radiologist) as specified in the “Agreement to Provide Local Health Services”. If a GHP Plan B member receives a bill for services on & after 02/01/2006 for facility services, please contact GHP.
Not covered:
- Nuclear radiology (includes tests like PET and radioisotope related procedures).
- Pain management services performed by a pain management specialist.
- Emergency room or after hours.
- Services related to ER or after hours.
- Chemotherapy
- IV Infusion Therapy
- Dialysis
- Sleep studies
- 23-hour holds, dental related services and cardiac rehab.
|
$3 Copay: Professional FOR ALL SERVICES IN OUTPATIENT HOSPITAL
$5 Copay: Facility/hospital FOR COVERED SERVICES.
|
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Pharmacy
|
Covered: if ordered by an MD, DO, or NP. Please refer to your handbook for brand and generic drug rules.
|
$3 copayment
No copays for diabetic drugs or supplies
- $40 out of pocket maximum copay
|
|
Physical Therapy
|
Evaluation Only
Effective May 1, 2006, limited pre-op, post-op and pain management therapy services are available. Contact GHP for authorization.
|
N/A |
|
Physician
Nurse Practitioner
Oral Surgeon
Medical Clinic
|
- Annual physical exams (including a pelvic and breast exam, and pap test). Women who qualify for screening/services under Breast and Cervical Cancer Programs administered by the Local Health Department may be referred to that program for services as appropriate.
- Diagnostic and treatment services. May refer to local health department for TB, STD or HIV-related services, as available and appropriate.
- General opthalmologic services (procedure codes 92002-92014).
- Immunizations per ACIP guidelines. May be referred to the local health department. Travel immunizations are excluded.
- Injections administered in a physician’s office per current Medicaid policy. Some injections may require prior authorization.
|
$3 copayment
|
|
Podiatrist
|
Limited services.
- When referred by a primary care physician for foot care related to Diabetes. Diagnosis codes 250.00-250.93 with procedure codes G0245, G0247 and G0246.
- When referred by a primary care physician for foot care related to Vascular Insufficiency. Diagnosis codes for rates 355.7-355.8 for procedure codes G0245, G0247 and G0246.
|
$3 copay
|
|
Prosthetics/Orthotics
|
Not covered
|
N/A
|
|
Private Duty Nursing
|
Not covered
|
N/A
|
|
Substance Abuse
|
May be covered through local Mental Health/Substance Abuse programs; most qualify through these agencies.
|
N/A
|
|
Therapies
|
Occupational, physical, and speech therapy evaluations are covered when provided by physicians in a free standing facility.
|
N/A
|
|
Transportation (including non emergency ambulance)
|
Not covered
|
N/A
|
|
Urgent Care Clinic
|
Not covered
|
N/A
|