Molinalogo

(Prior Authorization required)

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

- Preventive
- Diagnostic
- Restorative
$2000 calendar year limit
Other Dental Services
(maximum annual limit does not apply)

Annually

Freestanding or hospital-based center services

All Medicaid policy restrictions apply.

Limited to beneficiaries under 21 years of age.

No Limit

1 eye exam and 1 pair of glasses every year 100%

Inheritable disease diagnosis

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

(Care management review required)

Inpatient and Outpatient

Inpatient and Outpatient

Requires consent form with authorization request

All Medicaid policy restrictions apply.

To medical appointments, vision exams and pharmacy

Including but not limited to Thallium stress test or nuclear stress test

Including Prenatal

Inpatient/outpatient setting

All Medicaid policy restrictions apply.

24/7 Personal Care Managers available in clinics

No limit

Subject to qualifying systemic diagnosis

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, Well Child 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

Inpatient/Outpatient care

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