California Medi-Cal Medical Benefits
What does my health plan cover?
This page explains your covered services as a Member of IEHP. Your covered services are at no cost if they are medically necessary, and you get the approved services from our Provider network. “Medically necessary” means it is reasonable and needed to protect life, to keep you from becoming seriously ill or disabled, or to reduce pain from a diagnosed disease, illness or injury.
To learn more about IEHP’s benefits and services, read Chapter 4 of the IEHP Medi-Cal Member Handbook (PDF) or contact IEHP Member Services at (800) 440-IEHP (4347), TTY (800) 718-4347.
IEHP offers these types of services:
- Outpatient (ambulatory) services*
- Emergency services
- Transgender services*
- Hospice and palliative care*
- Maternity and newborn care
- Mental health services
- Prescription drugs
- Rehabilitative and habilitative services and devices*
- Laboratory and radiology services, such as X-rays*
- Preventive and wellness services and chronic disease management
- Sensitive services
- Substance use disorder treatment services
- Pediatric services
- Vision services*
- Non-emergency medical transportation (NEMT)
- Non-medical transportation (NMT)
- Long-term services and supports (LTSS)
- Telehealth services
Some of the services listed are covered only if IEHP or your IPA approves first. Covered services that may need an approval from IEHP or your IPA or medical group first are marked by an asterisk (*).
The plan covers:
- Routine eye exam once every 24 months; IEHP may pre-approve (prior authorization) additional services as medically necessary.
- Eyeglasses (frames and lens) once every 24 months; contact lens when required for medical conditions such as aphakia, aniridia and keratoconus
- Single vision lenses only.
- Members under 18 automatically get polycarbonate lenses.
- Contacts in lieu of glasses only if medically necessary.
Your provider can prescribe you drugs that are on the IEHP preferred drug list. This list is also called a Formulary. Drugs on the IEHP Formulary are safe and effective. To find out if a drug is on the Formulary or to get a copy of the IEHP Formulary mailed to you, call IEHP Member Services at 1-800-440-IEHP (4347) / TTY (800) 718-4347.
Sometimes IEHP needs to approve a drug before a provider can prescribe it. IEHP will review and decide on these requests within 24 hours.
- A pharmacist or hospital emergency room may give you a 72-hour emergency supply if they think you need it. IEHP will pay for this supply.
- If IEHP denies to the request, IEHP will send you a letter that tells you why and what other drugs or treatments you can try instead.
Exclusions and Limitations
IEHP does not cover:
- Drugs or medicines prescribed solely for cosmetic reasons
- Over-the-counter medicines (unless approved by IEHP)
- Non-FDA approved medicines
- Investigational medicines
- Medicines excluded from the Federal coverage (i.e., erectile dysfunction drugs)
- Medicines carved out by Fee-for-Service Medi-Cal
- Therapies and medical equipment excluded from the Federal coverage or carved out by
- Fee-for-Service Medi-Cal (i.e., erectile dysfunction medical equipment)
You can get a copy of the Formulary by calling IEHP Member Services at 1-800-440-IEHP (4347) (TTY 1-800-718-4347). The call is toll free.
If you fill or refill a prescription, you must get your prescribed drugs from a pharmacy that works with IEHP. You can find a list of these network pharmacies in the IEHP Provider Directory. You can also use the IEHP Provider Search tool on our website or you can call IEHP Member Services at 1-800-440-IEHP (4347) / TTY (800) 718-4347.
Once you choose a pharmacy, take your prescription there. Give them your prescription, along with your IEHP Member ID card. Make sure they know all the medicines you take and any allergies you have. If you have any questions about your medicines, make sure you ask the pharmacist.
The Medi-Cal Dental Program covers some dental services, such as:
- Diagnostic and preventive dental hygiene (e.g., examinations, x-rays, and teeth cleanings)
- Emergency services for pain control
- Tooth extractions
- Root canal treatments
- Prosthetic appliances
- Orthodontics for children who qualify
Members can access dental services through providers enrolled in the Medi-Cal Dental Program. They will advise you on the best course of treatment and when these services may be attained.
Your Medi-Cal benefits include round trip transportation for plan-covered health services and Medi-Cal-covered services, such as mental health, substance abuse and dental, within San Bernardino and Riverside counties.
The plan covers:
- Visits to your Primary Care Doctor, Specialists and urgent care clinics.
- Visit for dental, mental health, substance abuse and other services.
Exclusions and Limitations
IEHP does not cover:
- One-way trips and non-medical visits.
- Visits to Social Security, Workers Compensation Claims, Personal Injury cases, Courts, Parole or Probation or Social Services Offices.
IEHP offers two types of transportation:
- Bus passes* for Non-Medical Transportation (NMT): approved when you do not have any physical or medical issue that does not allow you to travel by bus, car, taxi or other forms of public transportation.
- Uber for Non-Medical Transportation (NMT): approved when your area doesn’t support bus passes, or you are crossing counties. For this type of transportation, you need to wait for your ride at the curb.
- Non-Emergent Medical Transportation (NEMT): approved when your medical or physical issue does not allow you to travel by bus, car, taxi or other forms of public transportation. For this type of transportation, your Doctor must submit a Physicians’ Certification Statement online.
Effective March 1, 2020, transportation for routine medical visits including Behavioral Health and Substance Use must be scheduled five business days before your appointment. To set up transportation, call IEHP Transportation Department at 1-800-440-4347 (option two), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347 (option two).
*For bus passes, call American Logistics Company at 855-673-3195 selection option 1. Once you get your bus pass, you can use this for all of your health care visits.
The Provisional Postpartum Care Extension Program
The Provisional Postpartum Care Extension (PPCE) Program provides extended coverage for Medi-Cal members who have a maternal mental health condition during pregnancy or the time period after pregnancy. IEHP covers maternal mental health care for women during pregnancy and for up to two months after the end of pregnancy. The PPCE program extends that coverage for up to 12 months after the diagnosis or from the end of the pregnancy, whichever is later.
To qualify for the PPCE program, your doctor must confirm your diagnosis of a maternal mental health condition within 150 days after the end of pregnancy. Ask your doctor about these services if you think you need them. If your doctor thinks you should have the services from PPCE, your doctor completes and submits the forms for you.
If you have questions, call IEHP Member Services at 1-800-440-IEHP (4347)(TTY 1-800-718-4347). IEHP is here Monday through Friday, from 8am to 5pm. The call is toll free.
For some types of care, your PCP or specialist will need to ask IEHP for permission before you get the care. This is called asking for prior authorization, prior approval, or pre-approval. It means that IEHP must make sure that the care is medically necessary or needed based on appropriateness of care and services and existence of coverage. Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or reduces severe pain from a diagnosed disease, illness or injury.
For some services, you need pre-approval (prior authorization). Under Health and Safety Code Section 1367.01(h)(2), IEHP will decide routine pre-approvals within 5 working days of when IEHP gets the information reasonably needed to decide.
For requests in which a provider indicates or IEHP determines that following the standard timeframe could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function, IEHP will make an expedited (fast) pre-approval decision. IEHP will give notice as quickly as your health condition requires and no later than 72 hours after receiving the request for services.
If IEHP does not approve the request, IEHP will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision. IEHP will contact you if IEHP needs more information or more time to review your request.
Continuity of Care
If you now go to providers who are not in the IEHP network (out-of-network), in certain cases you may get continuity of care and be able to go to them for up to 12 months. If your providers do not join the IEHP network by the end of 12 months, you will need to switch to providers in the IEHP network. If you are a new Member, you may request to keep getting medical services from an out of network provider if you were getting this care before enrolling in IEHP. IEHP will decide if this treatment with an out of network provider is medically appropriate. Continuity of care does not extend to durable medical equipment, transportation, ancillary services, carved out services or services not covered by Medi-Cal.
To learn more about continuity of care and eligibility qualifications, call IEHP Member Services at 1-800-440-IEHP (4347).