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2026 Plan Benefits

2026 Plan Benefits and Cost Sharing

These are your IEHP DualChoice plan benefits and costs for 2026.

Benefits

  • Doctor visit: $0
  • Vision care: a combined limit of  $350 each year for contact lenses and/or eyeglasses (frames and lenses)
  • Inpatient hospital care: $0
  • Home health agency care: $0
  • Ambulance services: $0
  • Transportation: $0. Including bus pass. Contact Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call 711. For reservations, call Monday-Friday, 7 a.m.-6 p.m. (PST). Call at least five days before your appointment.
  • Diagnostic tests, X-rays and lab services: $0
  • Durable medical equipment: $0
  • Home and Community-Based Services (HCBS): $0
  • Community-Based Adult Services (CBAS): $0
  • Long-term care that includes custodial care and facility: $0
  • Over-the-counter (OTC) item allowance of $60 per quarter (every three months) toward the purchase of certain OTC items.

You pay a low or no-cost copay for a one-month or long-term supply of drugs

With IEHP DualChoice, you pay a low or no-cost copay for covered drugs if you follow the plan’s rules. Your copay depends on how much “Extra Help” you get from Medicare, based on your income and resources.

  • Tier 1 drugs are preferred generic drugs. You pay $0 for drugs on this tier. 
  • Tier 2 drugs are generic drugs and have the lowest copay. The copay ranges from $0 to $5.10.
  • Tier 3 drugs are brand name drugs and have a higher copay. The copay ranges from $0 to $12.65.
  • Tier 4 drugs have a higher copay. They’re non-preferred drugs that include both brand and generic drugs.  The copay ranges from $0 to $12.65.
  • Tier 5 drugs are specialty drugs and have a higher copay. The copay ranges from $0 to $12.65.
  • Tier 6 drugs are select care drugs. You pay $0 for drugs on this tier.

After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.

 

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook

Plan premium

There is a monthly premium of $0-$12 for IEHP DualChoice. You may qualify for “Extra Help,” which can help reduce your monthly premium.

Plan deductible

There is no deductible for IEHP DualChoice.

 

Because you are eligible for Medi-Cal, you qualify for and are getting Extra Help from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help. 

 

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify to get Extra Help, you can contact:

How to get care coordination

Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator or other health professional.

 

 A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources if IEHP DualChoice does not provide the services that you need.

 

To speak with a care coordinator, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8 a.m. -8 p.m. (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.

Prior authorization and out of network coverage

You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP):

  • Preventive services
  • Routine women’s health care and family planning services. This includes breast exams, screening mammograms (X-rays of the breast), Pap tests and pelvic exams from a network provider.
  • Flu shots, COVID-19 vaccinations, hepatitis B vaccinations and pneumonia vaccinations from a network provider.
  • Emergency services from network or out-of-network providers.
  • Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside our plan’s service area. If possible, please call IEHP DualChoice Member Services before you leave the service area. We can help you receive dialysis while you’re away.
  • Sexually transmitted infection (STI) diagnosis and treatment
  • Sensitive confidential services
  • HIV testing and counseling at the Local Health Department
  • Biomarker testing for advanced or metastatic stage 3 or 4 cancers
  • If you are an American Indian member, you can get covered services from an Indian health care provider of your choice, without requiring a referral from the network PCP or prior authorization.

How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

  • Oncologists for care of patients with cancer.
  • Cardiologists for care of patients with heart conditions.
  • Orthopedists for care of patients with certain bone, joint or muscle conditions.

You will usually see your PCP first for most of your routine healthcare needs, such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group.

It is very important to get a referral (approval in advance) from your PCP before you see a plan specialist or certain other providers. If you don’t have a referral before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use. 

What if a specialist or another network provider leaves our plan?

Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can help you find and choose another provider.

How to get care from out-of-network providers

When your doctor suggests services that are not offered in our network, you can get these services from an out-of-network provider. To get out-of-network services, your PCP or specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.

 

IEHP DualChoice (HMO D-SNP) is an HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 



Information on this page is current as of October 1, 2025.
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