2015 Apple Health Benefit Grid Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Allergy Testing/ Serum
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered by DSHS
Surgeries: Sclerotherapy (Varicose Veins)
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Mammogram: Screening
Not required
Members may self refer to contracted providers. If provider is not in network then plan approved referral is required.
Yes
Yes
No, not covered
Injections: Alpha-1Proteinase Inhibitor (Aralst Np, Glassia, Prolastin, Zemaira)
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Injections: C1 Esterase Inhibitor (Berinert/Cinryze)
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Injections: Canakinumab (Ilaris)
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan
No, not covered
Injections: Ecallantide (Kalbitor) Injections: Erythropoiesis Stimulating Agents (Darbepoetin, Epoetin) Injections: Ibandronate (Boniva) Injections: Icatibant Acetate (Firazyr) Injections: Infliximab (Remicade) Injections: Ipilimumab (Yervoy)
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan
Required
Prior authorization Prior authorization
Required
Prior authorization
Required
Prior authorization
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan
No, not covered
Required
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered No, not covered
No, not covered No, not covered No, not covered
Page 1
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Vitamins: B12 Injections
Not required
If provider is participating in network then physician's order is required. If provider is not in network plan approved referral is required.
Yes
Yes
No, not covered
Vocational Rehabilitation
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Wound Care: Outpatient
Not required
If provider is participating then physician's order is required. If provider is NOT participating then plan approved referral is required.
Yes, more than 4 specialty visits per provider for each calendar year will require a prior authorization
Yes, more than 4 specialty visits per provider for each calendar year will require a prior authorization
No, not covered
Home Health Agency
Required
Prior authorization
See Covered Services Section
If provider is participating then a physician's order is required. If provider is NOT participating then a plan approved referral is required.
Yes, must be determined medically necessary by the plan For members 20 years of age and younger: More than 12 visits per calendar year will require a prior authorization.
No, not covered
Rehabilitation: Outpatient Physical Therapy
Yes, must be determined medically necessary by the plan For members 21 years of age and older: Initial evaluation, re- evaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without prior authorization. Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with prior authorization.
Screening, Brief Intervention, Referral and Treatment (SBIRT)
Not required
SBIRT 1 screening and 4 brief interventions so total of 5 units for these two codes (99408 & 99409) per year
Yes, when client is age 18 or older
Not covered for members younger than 17
No, not covered
Genetic Counseling and Testing: Non-Prenatal
Required
Prior Authorization
Genetic services, including testing, counseling and laboratory services, when medically necessary for diagnosis of a medical condition
Genetic services, including testing, counseling and laboratory services, when medically necessary for diagnosis of a medical condition
No, not covered
Allergy Injections
Not required
If provider is participating then physician's order is required. If provider is NOT participating then plan approved referral is required.
Yes
Yes
No, not covered by DSHS
Allergy Office Visit
Not required
If provider is participating then physician's order is required. If provider is NOT participating then plan approved referral is required.
Yes
Yes
No, not covered by DSHS
Alternative Care: Acupuncture
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
Page 2
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Alternative Care: Biofeedback Therapy
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered by DSHS. CHPW enhanced benefit.
Alternative Care: Chiropractic Treatment
Only required when >12 visits are billed for children who are eligible for it to be a covered service.
Provider must be a licensed chiropractor. If provider is participating then a physician's order is required. If provider is NOT participating then a plan approved referral is required.
Not covered for members 21 years of age or older
Covered for children only (age 20 and younger) with referral from PCP after well child screening
To be eligible, clients must be 20 years of age and younger and referred by a screening provider under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Please refer Chiropractic Services for Children Billing Instructions. See http://www.hca.wa.gov/medic aid/billing/documents/ guides/chiropractic_service
Alternative Care: Homeopathy
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Alternative Care: Hypnotherapy Alternative Care: Massage Therapy Alternative Care: Naturopathic Physicians (Naturopathy)
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Not required
CHPW contracts with naturopaths for specialty care services that fall within the scope of the naturopath’s license, are services covered under Medicaid FFS, and are prescription drugs included in the CHPW formulary. Every service or treatment normally provided by a naturopath may not be covered under the CHPW member’s plan. Naturopath providers contracted as CHPW specialists may not refer members for other services. The member must go back to their PCP for referral requests.
Yes
Yes
No, not covered
Alternative Care: Osteopathic Manipulative Therapy
Not required
Provider must be participating, and a physician's order is required
LIMITED benefit: Ten (10) osteopathic manipulations per calendar year are covered by the health plan, only when performed by a plan Doctor of Osteopathy (D.O.).
LIMITED benefit: Ten (10) osteopathic manipulations per calendar year are covered by the health plan, only when performed by a plan Doctor of Osteopathy (D.O.).
No, not covered by DSHS
Ambulance: Ground
Not required
No requirement (par/non-par)
Yes
2015 CHPW Apple Health Benefit Grid
Yes 12/19/2014
No, not covered by DSHS
Page 3
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Ambulance: Air
No, not covered
No, not covered
No, not covered
No, not covered
Ambulance: Facility-To- Facility
Not required
Yes
Attention Deficit Disorder (See Mental Health) Birth Control (See Family Planning) Birth Defects and Congenital Anomalies: Office Visits
(See Mental Health) (See Family Planning) Not required
Yes. Must be transportation to a higher level care facility. Not to a hospital providing an equivalent or lower level of care. (See Mental Health)
Yes, covered by DSHS. Air ambulance claims must be submitted to DSHS. Effective date: 05/01/2013. No, not covered by DSHS
(See Mental Health)
(See Mental Health)
(See Mental Health)
(See Family Planning)
(See Family Planning)
(See Family Planning)
(See Family Planning)
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered by DSHS
Birth Defects And Congenital Anomalies: Surgical Treatment
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered by DSHS
Pain Clinic: Alternative Care
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
DME: Breast Pumps Electric Purchase only. Limit of 1 per client per lifetime.
Required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
DME: Breast Pumps Hospital Grade Rental only. If client received a kit during hospitalization, an additional kit will not be covered. Maternity Support Services
Required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Part of the First Steps Program. Call 1-800-322-2588.
Blood/Blood Component
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, including but not limited to, synthetic factors, plasma expanders, and their administration
Yes, including but not limited to, synthetic factors, plasma expanders, and their administration
No, not covered by DSHS
Cardiac Rehabilitation
Required
Prior authorization
(See Chemical Dependency)
(See Chemical Dependency)
Yes, when determined to be medically necessary by the plan (See Chemical Dependency)
No, not covered by DSHS
Alcohol and Substance Abuse Services, Inpatient, Outpatient, and Detoxification
Yes, when determined to be medically necessary by the plan (See Chemical Dependency)
2015 CHPW Apple Health Benefit Grid
Yes
12/19/2014
Must be provided by Department of Social and Health Services (DSHS) certified agencies. Call 1-877301-4557 for specific information
Page 4
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Chemical Dependency (Alcohol and Drug): Detoxification
Not required
See Covered Services Section
No, except in cases when there are medical conditions secondary to chemical dependency treatment that require medical attention in emergent, inpatient or outpatient basis (lacerations, seizure, cirrhosis, dehydration).
Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service
Chemical Dependency (Alcohol and Drug): Inpatient Treatment
No, not covered
No, not covered
No, except in cases when there are medical conditions secondary to chemical dependency treatment that require medical attention in emergent, inpatient or outpatient basis (lacerations, seizure, cirrhosis, dehydration) No, not covered
No, not covered
Chemical Dependency (Alcohol and Drug): Partial Hospitalization Chemical Dependency (Alcohol and Drug): Outpatient (counseling sessions)
No, not covered
No, not covered
No, not covered
No, not covered
Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Chemical Dependency (Alcohol and Drug): Residential Treatment Circumcision: Routine
No, not covered
No, not covered
No, not covered
No, not covered
Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Circumcision: Medical Condition
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Cochlear Implants, Hearing Hardware Complications from NonCovered Service
Required
Prior authorization
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when determined to be medically necessary by the plan Yes, excluded for a period of 90 days starting the day after the DOS of the non-covered service
Yes, when determined to be medically No, not covered necessary by the plan Yes, excluded for a period of 90 days No, not covered starting the day after the DOS of the noncovered service
Cosmetic Services
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Court Ordered Services
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Custodial/Convalescent Care
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Dental: Anesthesia
No, not covered
No, not covered
No, not covered
No, not covered
Yes, refer to the Department of Aging and Adult Services at 206-341-7750
2015 CHPW Apple Health Benefit Grid
12/19/2014
Page 5
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Dental: Accidental Services
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when services are not performed by a dentist or oral surgeon
Yes, when services are not performed by a dentist or oral surgeon
Yes, dental care provided by dentist and some limited orthodontics
Dental: Routine Services
No, not covered
No, not covered
No, not covered
No, not covered
Yes, limited routine dental services are covered as a feefor-service, refer to DSHS
Dental: Medically Necessary Services
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when services are not performed by a dentist or oral surgeon
Yes, when services are not performed by a dentist or oral surgeon
Yes, when services are performed by a dentist or oral surgeon
Developmental Disabilities (see Neurodevelopment Therapy)
(See Neurodevelop ment Therapy) Required
(See Neurodevelopment Therapy)
(See Neurodevelopment Therapy)
(See Neurodevelopment Therapy)
(See Neurodevelopment Therapy)
Prior authorization
Yes, must be determined medically necessary by the plan
Yes, must be determined medically necessary by the plan
No, not covered
(See Prescriptions, Pharmacy)
(See Prescriptions, Pharmacy)
(See Prescriptions, Pharmacy)
(See Prescriptions, Pharmacy)
DME: Apnea Monitor
(See Prescriptions, Pharmacy) Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, limited to three (3) months of rental
Yes, limited to three (3) months of rentals
No, not covered
DME: Bras Post Surgical
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, 2 bras covered post mastectomy only
Yes, 2 bras covered post mastectomy only
No, not covered
DME: Breast Pumps Manual Purchase only. Limit of 1 per client per lifetime.
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
DME: Communication Devices
Required
Prior authorization
Yes
Yes
No, not covered
DME: C-Pap/Bi-Pap 2 month rental, Auto-Titration DME: C-Pap/Bi-Pap Purchase
Required
Prior authorization Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary Yes, must be determined medically necessary by the plan
Dialysis (hemodialysis, peritoneal, renal (kidney failure) Drugs (see Prescriptions, Pharmacy)
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
Page 6
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
DME: Diabetic Supplies
Not required
Prescription
Yes, these supplies can be obtained with prescription at a participating pharmacy. See Fee-For-Service DSHS Coverage for more information.
Yes, these supplies can be obtained with prescription at a participating pharmacy. See Fee-For-Service DSHS Coverage for more information.
DME: Incontinent Supplies (briefs, pull-ups, liners)
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, disposable briefs and pull-up pants (any size) are limited to: 150 per month for an adult 19 years of age and older. Disposable pant liners, shields, guards, pads, and undergarments are limited to 200 per month.
Yes, disposable briefs and pull-up pants (any size) are limited to: 200 per month for a child age 3 to 18 years of age. Disposable pant liners, shields, guards, pads, and undergarments are limited to 200 per month.
Effective for dates of service on and after August 1, 2009, CHP will pay for blood glucose test strips and lancets as follows: 100 per 3 months if the member is not insulin‐dependent; or 100 per month if the client is insulindependent No, not covered
DME: Enteral Therapy Formula
Required
Prior authorization
Required
Prior authorization
DME: Fracture Frames
PA for purchase not required. PA for rental required.
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes. Oral enteral nutrition is a covered service for members 20 years of age and younger. Yes, must be determined medically necessary by the plan (prior authorization) Yes
No, not covered
Enteral Therapy Pump Rental
No. Oral enteral nutrition is not covered for members 21 years of age and older. Yes, must be determined medically necessary by the plan (prior authorization) Yes
DME: Hospital Bed
Required
Prior authorization
Yes
Yes
No, not covered
DME: Humidifiers
Required
Prior authorization
Yes
Yes
No, not covered
DME: Insulin Pump
Required
Prior authorization
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, must be determined medically necessary by the plan Yes, covered as part of cancer treatment
No, not covered
DME: Lymphedema Sleeve
Yes, must be determined medically necessary by the plan Yes, covered as part of cancer treatment
DME: Nebulizer
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, purchase only
Yes, purchase only
No, not covered
DME: Oseogen (Bone Growth Stimulator) DME: Oxygen & Related Equipment
Required
Prior authorization Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered No, not covered
No, not covered
No, not covered
Page 7
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
DME: Prenatal Therapy and Supplies
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, must be determined medically necessary by the plan
Yes, must be determined medically necessary by the plan
No, not covered
DME: Patient Lifts
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
DME: Suction Pumps
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
DME: Chest Compression Devices DME: Cough Stimulating Devices
Required
Prior authorization If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Not required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
DME: Wound Vac
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Surgeries: Shoulder Arthroscopy Surgeries: Urethral Suspension
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
No, not covered No, not covered
Page 8
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Medical Nutrition Therapy
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
No, not covered
Medical Nutrition Therapy is covered for all Medicaid LOB’s for ages 20 & younger, when referred by PCP or pediatrician during an EPSDT exam. Referrals must be for the listed “appropriate conditions” in HRSA/HCA billing guidelines to Certified Dieticians. Please see Medical Nutrition Therapy Provider Guide in HRSA/HCA billing guidelines: http://hrsa.dshs.wa.gov/billing/documen ts/guides/medical_nutrition_therap y_bi.pdf. Provider Specialties that may be paid for Medical Nutrition Therapy: Advanced Registered Nurse Practitioners (ARNP) Certified Dieticians Durable Medical Equipment (DME) Health Departments Outpatient Hospitals and Physicians.
No, not covered
Psychiatric Care, Inpatient and Crisis Services (see Mental Health for more information)
No, not covered
No, not covered
No, not covered
No, not covered
All mental health services when received from a community mental health agency. Inpatient psychiatric care must be authorized by a mental health professional from the local community mental health agency. For more specific information, call 1-800-446-0259.
DME: TENS Unit (Covered under Medicare only) DME: Trapeze Bars
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
DME: Ventilators and Related Equipment DME: Wheelchairs, Scooters
Required
Prior authorization Prior authorization
Emergency Room Services Experimental / Investigational Services and Drugs
Not required Required
No requirement Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes Yes, when determined to be medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes Yes, when determined to be medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered No, not covered No, not covered
Page 9
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Eye Ball Polishing
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Eye Exam: Routine
Not required
Yes, one every twenty-four months (21 and older)
Yes, one every twelve months (20 and younger)
Yes, fabrication services & associated fitting services are covered.
Eye Exam: Medical Condition (diagnose and treated)
Not required
Members may self-refer to contracted providers. If provider is not in network then plan approved referral is required. If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Eyeglasses and Fitting Services
No, not covered
No, not covered
No, not covered
No, not covered
Covered for clients under age 21. You will need to use an Apple Health fee-for-service provider. Refer to DSHS.
Family Planning: Contraception (emergency) Contraceptive Devices: Prescriptions & Implants
Not required
Prescription
Yes, at a participating pharmacy
Yes, at a participating pharmacy
No, not covered
Not required
Prescription
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes, birth control pills Medroxyprogesterone injection, Nuvaring™, Ortho‐Evra™ Yes, Depo Provera™ and Mirena™ are covered
No, not covered
Contraceptive Devices: Injections
Yes, birth control pills Medroxyprogesterone injection, Nuvaring™, Ortho‐Evra™ Yes, Depo Provera™ and Mirena™ are covered
2015 CHPW Apple Health Benefit Grid
12/19/2014
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: • Medicaid-approved family planning provider • A Medicaid agencycontracted local health department/STI clinic • A Medicaid agencycontracted provider who provides abortion services • A Medicaid agencycontracted pharmacy
Page 10
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Contraceptive Devices: IUD
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes, cervical caps, diaphragms and IUD’s are covered
Yes, cervical caps, diaphragms and IUD’s are covered
Contraceptive Devices: Over The Counter Products Maternity Services: Outpatient
Not required
Prescription
Yes, condoms, gels, foams, and creams
Yes, condoms, gels, foams, and creams
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: • Medicaid-approved family planning provider • A Medicaid agencycontracted local health department/STI clinic • A Medicaid agencycontracted provider who provides abortion services • A Medicaid agencycontracted pharmacy No, not covered by DSHS
Not required
Member may self‐refer to contracted providers. If provider is not in network then plan approved referral is required.
Yes
Yes
Maternity Services: Inpatient
Not required
Hospital notification
Yes
Yes
2015 CHPW Apple Health Benefit Grid
12/19/2014
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agency-contracted local health department/STI clinic A Medicaid agency-contracted provider who provides abortion services A Medicaid agency- contracted pharmacy No, not covered
Page 11
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Family Planning: Outpatient (includes observations)
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes
Yes
Family Planning: Office Visits
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes
Yes
Family Planning: Home Delivery
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility
Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agency-contracted local health department/STI clinic A Medicaid agency-contracted provider who provides abortion services A Medicaid agency- contracted pharmacy Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agency-contracted local health department/STI clinic A Medicaid agency-contracted provider who provides abortion services A Medicaid agency- contracted pharmacy Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agency-contracted local health department/STI clinic A Medicaid agency-contracted provider who provides abortion services A Medicaid agency- contracted pharmacy
2015 CHPW Apple Health Benefit Grid
12/19/2014
Page 12
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Family Planning: Newborn Care
Not required
Greater than 5 days in the hospital requires a separate hospital notification. Less than 5 days is covered under mom's notification.
Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility
Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility
Family Planning: Sterilization for Women (includes tubal ligation)
Not required
Member may self‐refer to contracted providers. If provider is not in network then plan approved referral is required.
No, not covered
Forensic Exam
No, not covered
No, not covered
Yes, must be older than 21 years of age and sign a consent form and wait 30 days after signature. (30 day requirement may be waived in cases of premature delivery or emergency abdominal surgery ) No, not covered
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agency-contracted local health department/STI clinic A Medicaid agency-contracted provider who provides abortion services A Medicaid agency- contracted pharmacy Yes, for member less than 21 years old and those who do not meet other federal requirements. They must sign a consent form and wait 30 days No, not covered
Genetic Counseling and Testing: Prenatal is Not a Covered Benefit
No, not covered
No, not covered
No, not covered
No, not covered
One initial prenatal genetic counseling service billable for each 30 minutes up to 90 minutes. Face to face encounters only. (Telephonic/email encounters are not covered.) Two followup prenatal genetic counseling encounters, billable for each 30 minutes up to 90 minutes per encounter, per pregnancy (within an 11- month period).
Injections: Pegloticase (Krystexxa) Injections: Ustekinumab (Stelara) Health Education and Wellness Programs: Asthma Education
Required
Prior authorization Prior authorization
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, covered up to 6 combined (group and/or individual) visits per calendar year
No, not covered
Required
Yes, when determined to be medically necessary by the plan Yes, when determined to be medically necessary by the plan Yes, covered up to 6 combined (group and/or individual) visits per calendar year
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
No, not covered No, not covered
Page 13
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Health Education and Wellness Programs: Diabetic Education
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, up to six hours of diabetes education/diabetes management per client, per calendar year
Yes, up to six hours of diabetes education/diabetes management per client, per calendar year
No, not covered
Health Education and Wellness Programs: Nutritional Counseling
May require prior authorization. Check procedure codes for more details Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
No, not covered
Covered for clients under age 21 when medically necessary and referred by the provider after an EPSDT screening
No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
No, not covered
No, not covered.
Hearing Exams (audiology)
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, examinations to determine hearing loss
Yes, covered age 20 and younger when determined to be medically necessary by the Plan. Hearing aids, including fitting, follow-up care, batteries, and repair, are covered. Yes, examinations to determine hearing loss
HIV/Aids- Screening
Not required
Yes
Yes
Yes, if member self refers to the public health departments or family planning clinics
Out of Area Coverage: Routine, Preventive Care, Routine Vaccines Home Health Care
No, not covered
You have a choice of going to a family planning clinic, the local health department, or going to your PCP for the screening No, not covered
No, not covered
No, not covered
No, not covered
Required
Prior authorization is required
Yes, must be determined medically necessary by the plan. Includes private duty nursing per HRSA Guidelines.
Yes, must be determined medically necessary by the plan. Includes private duty nursing per HRSA Guidelines.
No, not covered
Home Infusion Therapy
Required
Prior authorization
Yes, must be determined medically necessary by the plan
No, not covered
Home Intrauterine Activity Monitoring (Fetal Heart Monitor) Home Phototherapy Hyperbilirubinemia
No, not covered
No, not covered
No, not covered
Yes, must be determined medically necessary by the plan (prior authorization) No, not covered
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Hospice Care
Required
Prior authorization
Yes, when determined to be medically necessary by the plan. Includes private duty nursing per HRSA Guidelines.
Yes, when determined to be medically necessary by the plan. Includes private duty nursing per HRSA Guidelines.
No, not covered
Hearing Aid Devices, Hearing Hardware
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
No, not covered
Page 14
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Hospital Care: Inpatient
Inpatient hospital notification - all admits May require prior authorization. Check procedure codes for more details Not required
Prior authorization is required for all planned inpatient stays
Yes, prior authorization is required for all planned inpatient stays. Hospital notification is required for all inpatient stays. Yes
Yes, prior authorization is required for elective inpatient stays. Hospital notification is required for all non‐ elective inpatient stays. Yes
No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Hyperbaric Oxygen Pressurization Immunizations
Required
Prior authorization No requirement when administered by the PCP and/or the public health department (par only)
Yes, must be determined medically necessary by the plan Yes
No, not covered
Not required
Yes, must be determined medically necessary by the plan Yes
Immunizations: Flu Vaccinations
Not required
No requirement when administered by the primary care provider and/or the public health department (participating provider only)
Yes, FluMist™ is covered for ages 2‐49 only
Yes, FluMist™ is covered for ages 2‐49 only
No, not covered
Immunizations: Menactra® (meningococcal vaccine)
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, covered for members age 19 under the following conditions: if member is entering college as a freshman and living in a dorm, if member has functional or anatomic asplenis, if member has terminal complement component deficiencies, if member has HIV/AIDS.
Yes, covered for members age 11, 12, 15 No member cost sharing for or 18 under the following conditions: If preventive health services member is entering college as a freshman and living in a dorm, if member has functional or anatomic asplenis, if member has terminal complement component deficiencies, if member has HIV/AIDS.
Immunizations: Proquad (Measles, Mumps, Rubella)
No, not covered
No, not covered
No, not covered
No, not covered
Yes, for children only; noncovered for adults
Immunizations: Pediatric
No, not covered
No, not covered
No, not covered
No, not covered
Rotavirus Vaccine (Rotateq®)
No, not covered
No, not covered
No, not covered
No, not covered
Yes, for children only; noncovered for adults Yes, covered for Healthy Options members by DSHS FFS
Immunizations: Varicella vaccine (Chicken Pox) Impotence Treatment
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Hospital Care: Outpatient Surgery
HPV (Human Papilloma Virus) Test
2015 CHPW Apple Health Benefit Grid
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
12/19/2014
No, not covered
No, not covered
Page 15
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Incarcerated Care
Required
Services to inmates of correctional facilities: the contractor shall provide inpatient hospital services to enrollees who were inmates of correctional facilities, and are admitted to the hospital for an overnight stay. When an enrollee who was an inmate of a correctional facility is admitted to the hospital, the contractor will submit all necessary information to HCA regarding the admission. HCA will determine if the enrollee is eligible for coverage of the hospital stay. If HCA determines that the enrollee is eligible for coverage, the contractor is responsible for the hospital stay and all associated services.
Yes, please see comments in the Requirements field
Yes, please see comments in the Requirements field
Yes, please see comments in the Requirements field
Infertility, Impotence and Sexual Dysfunction
No, not covered
No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization
No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization
No, not covered
Injections: Botulinum toxin (Botox®/Myobloc®) Injections: Etanercept (Enbrel®)
Required
No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization Prior authorization Prescription + ESI PA (if selfadministered) Prior authorization (only if member is unable to self-administer)
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
Injections: GnRH Agonists (e.g. Lupron) Injections: Growth Hormone (Somatropin®)
Required
Prior authorization Prescription + ESI PA (if selfadministered) Prior authorization (only if member is unable to self-administer)
Yes, when determined to be medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Required
Yes, when determined to be medically necessary by the plan Yes, must be determined medically necessary by the plan
Injections: Hyaluronic Acid Derivatives (e.g. Synvisc, Hyalgan) Injections: Panitumumab (Vectibix) Injections: Intravenous Immunoglobulin Injections: Peginesatide (Omontys)
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Required
Prior authorization Prior authorization
Required
Prior authorization
Yes, when determined to be medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, when determined to be medically necessary by the plan
No, not covered
Required
Yes, when determined to be medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, when determined to be medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
No, not covered
No, not covered No, not covered
Page 16
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Injections: Palivizumab (Synagis®) Injections: Iloprost (Ventavis®)
Required
Prior authorization Prior authorization
Injections: Natalizumab (Tysabri®) Injections: Omalizumab (Xolair®) Interpreter Services
Required
Prior authorization
Required
Prior authorization
Not required
IV Therapy: Outpatient
Yes
No, not covered
IV Therapy: Home
May require prior authorization. Check procedure codes for more details Required
No, except for administrative issues only. Such as handling member complaints and appeals. (See DSHS column for additional services available.) Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan No, except for administrative issues only. Such as handling member complaints and appeals. (See DSHS column for additional services available.)
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan No, except for administrative issues only. Such as handling member complaints and appeals. (See DSHS column for additional services available.) Yes
No, not covered
No, not covered
Yes, must be determined medically necessary by the plan No, not covered
No, not covered
Learning Disabilities
Yes, must be determined medically necessary by the plan No, not covered
Lymphedema Treatment
May require prior authorization. Check procedure codes for more details Required (See Chiropractic Care and Osteopathic Manipulation)
If prior authorization is not required: If provider is participating then a physician’s order is required. If provider is not participating then a plan approved referral is required.
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Prior authorization (See Chiropractic Care and Osteopathic Manipulation)
Yes (See Chiropractic Care and Osteopathic Manipulation)
Yes (See Chiropractic Care and Osteopathic Manipulation)
No, not covered (See Chiropractic Care and Osteopathic Manipulation)
Required
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Mammogram: Diagnostic Manipulation of Spine & Extremities (see Chiropractic)
Surgeries: Spinal
2015 CHPW Apple Health Benefit Grid
Prior authorization
12/19/2014
No, not covered No, not covered No, not covered Yes, for medical encounters & DSHS Fair Hearings. Interpreter must be certified w/ DSHS.
No, not covered
Page 17
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Mental Health: Inpatient
No, not covered
No, not covered
No, not covered
No, not covered
All mental health services when received from a community mental health agency. Inpatient psychiatric care must be authorized by a mental health professional from the local community mental health agency. For more specific information, call 1-800-446-0259.
Immunizations: Shingles (Herpes Zoster)
Only covered for over 60 years of age Required
No requirement
Only covered for over 60 years of age
No
No, not covered
Required
Required
Required
No, not covered
Only covered for over 60 years of age (See Eye Exam)
No requirement
Only covered for over 60 years of age
No
No, not covered
(See Eye Exam)
(See Eye Exam)
(See Eye Exam)
(See Eye Exam)
Mental Health: Outpatient Treatment
Not required
Yes
Yes
Yes, covered by DSHS fee‐ for‐service for those members that meet DSHS Access To Care Standard. Mental health provided by Regional Support Network (RSN), for RSN phone numbers. See: http://www.dshs.wa.gov/dbhr /rsn.shtml
Methadone Treatment
No, not covered
Mental health services are covered when provided by a psychiatrist, a psychologist, a licensed mental health counselor, a licensed clinical social worker, or a licensed marriage and family therapist. These services include: • Psychological testing, evaluation, and diagnosis. • Mental health treatment. • Mental health medication management by your PCP or mental h h covered d No, lnot
No, not covered
No, not covered
Neurodevelopment Therapy
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
Yes, covered by the Division of Behavioral Health and Recovery (DBHR). Call 1-877-301-4557. Fee-for-Service covers children only when services are performed in an approved neurodevelopmental center. See http://www.doh.wa.gov/Porta ls/1/Documents/Pubs/970-199NDCList.pdf.
Unlisted Codes with Charge > $1,000.00 Vaccinations Shingles Vision Services (See Eye Exam)
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12/19/2014
Page 18
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Neuropsychological Testing (CPT 96116, 96118, 96119) Weight Loss Procedures, not intended to treat obesity
Required
Prior authorization
Yes
Yes
No, not covered
Required.
Prior Authorization for the 3-stage program for bariatric surgery and only when medically necessary. Prior Authorized surgery services can only be performed in an approved hospital and associated clinic.
Yes.
Yes.
No, not covered.
Occupational Injuries
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Office Visit
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Orthoptic Therapy
No, not covered
No, not covered
No, not covered
No, not covered
Out of Area Coverage: Urgent Care (urgently needed care)
Not required
No requirement (par/non-par)
Yes
Yes
Fee-for-service may cover children No, not covered
Out of Area Coverage: Inpatient Out Of Area Coverage: ER Outpatient Diagnostic: Services, Procedures, and Tests
Not required
Hospital notification
Yes
Yes
No, not covered
Not required Not required
No requirement (par/non-par) No requirement (par/non-par)
Yes Yes
Yes Yes
No, not covered Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1877-301-4557.
Outpatient Diagnostic: Laboratory Services
Not required
There are no referral requirements for par/non-par providers
Yes
Yes
Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1877-301-4557.
Outpatient Diagnostic: Therapeutic Radiological Service MRI CAT Scans PET Scans, and X-Rays
May require prior authorization. Check procedure codes for more details
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, Pet Scans, some MRI, MRA, and CT Angiography require a prior authorization
Yes, Pet Scans, Some MRI, MRA, and CT Angiography require a prior authorization
No, not covered
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12/19/2014
Page 19
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Over the counter medications
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Pain Clinic: Office Visits
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Pain Clinic: Outpatient Rehabilitation
If prior authorization is not required: If provider is participating then a physician’s order is required. If provider is not participating then a plan approved referral is required.
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Pain Management
May require prior authorization. Check procedure codes for more details May require prior authorization. Check procedure codes for more details Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Palliative Care
Required
Prior authorization
Not required
No requirement (par/non-par)
Yes, covered in conjunction with hospice and must be determined medically necessary by the plan. Yes
No, not covered
Pathology Services
Yes, covered in conjunction with hospice and must be determined medically necessary by the plan. Yes
Physical Exams
Not required
Yes
Yes
No, not covered
PKU (Phenylketonuria) Formula
Not required
No requirement when done by the PCP If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
PKU (Phenylketonuria) Screening
No, not covered
No, not covered
No, not covered
No, not covered
Yes, DSHS will reimburse hospitals for newborn screenings for PKU and other metabolic disorders
Pain Clinic: Treatment (nerve block, epidural)
2015 CHPW Apple Health Benefit Grid
12/19/2014
Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1877-301-4557.
Page 20
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Podiatry (including diabetic foot care)
Not required
Routine care not covered. See limitations/exclusions for coverage. If provider is participating then a physician's order is required. If provider is not participating then a plan approved referral is required.
Yes
Yes
No, not covered
Prescriptions, Pharmacy: Inpatient Drugs
Not required
Covered under hospital notification (except inpatient psychiatric care, which is covered by DSHS)
Yes
Yes
Yes, for pharmacy products and prescriptions for self‐referred services from health depts., family planning clinics, RSN’s, DBHR programs and dentists.
DME: Durable Medical Equipment
Some DME requires prior authorization, check procedure codes for details. All DME with a purchase price greater than $500.00 allowed amount per line item or greater than $1,000 total allowed amount will require prior authorization.
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
Prescriptions, Pharmacy: Out of Area Drugs
May require prior authorization. Check procedure codes for more details May require prior authorization. Check procedure codes for more details
Prescription
Yes, members can obtain prescriptions when out of the service area and filled at a participating pharmacy
Yes, members can obtain prescriptions when out of the service area and filled at a participating pharmacy
No, not covered
Prescription
Yes, must be purchased at a participating pharmacy. Generic drugs will be dispensed unless the generic equivalent is not available. Protease inhibitors are not covered by CHP.
Yes, must be purchased at a participating pharmacy. Generic drugs will be dispensed unless the generic equivalent is not available. Protease Inhibitors are not covered by CHP.
Yes, for protease inhibitors
Prescriptions, Pharmacy: Outpatient Drugs
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Page 21
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Prescriptions, Pharmacy: Mail Order Prescriptions Prescriptions, Pharmacy: Take Home Drugs
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
Not required
No, not covered
Not required
No, must be obtained with a prescription at a participating pharmacy Yes, including but not limited to immunizations, well‐child checks, screening colonoscopies, mammograms and bone density testing. TDAP vaccines for pregnant or postpartum enrollees’ given in any setting (provider, pharmacy), whether or not ordered by the PCP. TDAP Tetanus, diphtheria and pertussis
No, must be obtained with a prescription at a participating pharmacy
Preventive Care, Routine Care, Vaccines
No, must be obtained with a prescription at a participating pharmacy No requirement when done by the PCP or School Based or Family Planning contracted providers
Yes, including but not limited to immunizations, well‐child checks, screening colonoscopies, mammograms and bone density testing. TDAP vaccines for pregnant or postpartum enrollees’ given in any setting (provider, pharmacy), whether or not ordered by the PCP. TDAP - Tetanus, diphtheria and pertussis
No, not covered
DME: Prosthetics and Orthotics (i.e, Prostheses, Breast Implants)
May require prior authorization. Check procedure codes for more details No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
May require prior authorization. Check procedure codes for more details May require prior authorization. Check procedure codes for more details May require prior authorization. Check procedure codes for more details Required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, some agents require prior authorization
Yes, some agents require prior authorization
No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, some agents require prior authorization
Yes, some agents require prior authorization
No, not covered
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, some agents require prior authorization
Yes, some agents require prior authorization
No, not covered
Prior authorization
Yes, when determined to be medically necessary by the plan
Yes, when determined to be medically necessary by the plan
No, not covered
Pulmonary Rehabilitation Radiation & Chemotherapy
Radiation & Chemotherapy: Oral Chemotherapy
Radiation & Chemotherapy: Injectable and Infused Chemotherapy
Rehabilitation: Inpatient
2015 CHPW Apple Health Benefit Grid
12/19/2014
Page 22
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Rehabilitation: Outpatient Occupational Therapy
See Covered Services Section
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
For members 21 years of age and older: Initial evaluation, re- evaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without prior authorization. Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with prior authorization.
For members 20 years of age and younger: More than 12 visits per calendar year will require a prior authorization.
No, not covered
Rehabilitation: Outpatient Speech Therapy
See Covered Services Section
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
For members 21 years of age and older: Initial evaluation, re- evaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without prior authorization. Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with prior authorization.
For members 20 years of age and younger: More than 12 visits per calendar year will require a prior authorization.
No, not covered
Respite Care (hospice) (see hospital Care) Reversal of Sterilization
(See Hospital Care) No, not covered
(See Hospital Care)
(See Hospital Care)
(See Hospital Care)
(See Hospital Care)
No, not covered
No, not covered
No, not covered
No, not covered
Injections: Rituximab (Rituxan®) Saliva Testing
Required
Prior authorization No, not covered
Yes, must be determined medically necessary by the plan No, not covered
No, not covered
No, not covered
Yes, must be determined medically necessary by the plan No, not covered
School Nurse Services
No, not covered
No, not covered
No, not covered
No, not covered
Only for special education students with individual/family special education plan (IFSP). School bills fee‐for‐service.
Screening Exams: (preventive) Colorectal (colonoscopy)
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, screening and diagnostic colonoscopies are covered
Yes, screening and diagnostic colonoscopies are covered
No, not covered
Screening Exams: (preventive)
Not required
No requirement (par/non-par)
Yes
Yes
No, not covered
Sexual Reassignment (Surgery, Services and Supplies)
No, not covered
No, not covered
No, not covered
No, not covered
Yes, may be covered by DSHS
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered
Page 23
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Skilled Nursing Facility
Required
Prior authorization
Yes, when medically necessary and when nursing facility services are not covered by Dept of Aging and Adult Services Administration. NOTE: CHP covers all physician services done at the SNF.
Yes, when approved by Dept. of Aging and Adult Services (AAS) 1‐800‐422‐3263
Sleep Study
Prior authorization (PA) is not required for the initial sleep study. One sleep study per calendar year is allowed and PA is required for any sleep study after the initial sleep study.
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, when medically necessary and when nursing facility services are not covered by Dept of Aging and Adult Services Administration. NOTE: CHP covers all physician services done at the SNF Yes, covered for obstructive sleep apnea and narcolepsy diagnoses only.
Yes, covered for obstructive sleep apnea and narcolepsy diagnoses only.
No, not covered
Smoking and Tobacco Cessation: Services
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, ages 18 and older are covered through Alere Quit-for-Life smoking cessation program. For questions, please call 1-866-784-8454.
Not covered for members younger than 18
No, not covered
Smoking and Tobacco Cessation: Drugs Smoking and Tobacco Cessation: Nicotine Replacement Substance Abuse (see Chemical Dependency)
Not required
Prescription
Yes
Yes
No, not covered
Not required
Prescription
Yes, some may be covered
Yes, some may be covered
No, not covered
(See Chemical Dependency)
(See Chemical Dependency)
(See Chemical Dependency)
(See Chemical Dependency)
(See Chemical Dependency)
2015 CHPW Apple Health Benefit Grid
12/19/2014
Page 24
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Abortion, Spontaneous (miscarriage)
Not required
Member may self‐refer to contracted women’s health care providers. If provider is not in network then plan approved referral is required.
Yes
Yes
Surgeries: Abortion, Voluntary
No, not covered
No, not covered
No, not covered
No, not covered
Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: • Medicaid-approved family planning provider • A Medicaid agencycontracted local health department/STI clinic • A Medicaid agencycontracted provider who provides abortion services • A Medicaid agencycontracted pharmacy No, not covered
Surgeries: Ambulatory Surgery (outpatient or same day surgery)
May require prior authorization. Check procedure codes for more details Yes. Required
Prior authorization
Yes, however some outpatient surgeries require PA. See specific surgery for additional information.
Yes, however some outpatient surgeries require PA. See specific surgery for additional information.
No, not covered
Prior Authorization for the 3-stage program for bariatric surgery and only when medically necessary. Prior Authorized surgery services can only be performed in an approved hospital and associated clinic.
Yes.
Yes.
No, not covered.
Required
Prior authorization Prior authorization
Yes, must be determined medically necessary by the plan Yes, initial reconstruction mammoplasty is covered regardless of whether the member was covered by CHP at the time of the original mastectomy. (See extra information for more info.)
No, not covered
May require prior authorization. Check procedure codes for more details Required
Yes, must be determined medically necessary by the plan Yes, initial reconstruction mammoplasty is covered regardless of whether the member was covered by CHP at the time of the original mastectomy. (See extra information for more info.)
No, not covered (see Additional Information column)
Yes, must be determined medically necessary by the plan No, not covered (see Additional Information column)
No, not covered
No, not covered (see Additional Information column)
Yes, must be determined medically necessary by the plan No, not covered (see Additional Information column)
Surgeries: Bariatric Surgery/ Weight Loss Procedures: not intended to treat obesity
Surgeries: Blepharoplasty (Eyelid Surgery) Surgeries: Mammoplasty
Surgeries: Breast Reduction Surgery Surgeries: Cosmetic or Plastic Surgery. Including tattoo removal, face lifts, ear or body
2015 CHPW Apple Health Benefit Grid
Prior authorization
12/19/2014
No, not covered
No, not covered (see Additional Information column)
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Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Surgeries: Eye Surgery (Lasik®)(for vision improvement) Surgeries: Eye Surgery (laser) (for a medical condition)
No, not covered
No, not covered
No, not covered
No, not covered
No, not covered
May require prior authorization. Check procedure codes for more details Required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, surgeries for a medical condition such as glaucoma, retinal detachment and cataracts are covered
Yes, surgeries for a medical condition such as glaucoma, retinal detachment and cataracts are covered
No, not covered
Prior authorization Prior authorization
Required
Prior authorization
Surgeries: Knee Replacement Surgery Surgeries: Mastectomy
Required
Prior authorization
Not required
If procedure is performed in an inpatient setting then a hospital notification is required. If procedure is outpatient and the provider is participating then a physician's order is required. If procedure is outpatient and the provider is not participating then a plan approved referral is required.
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes
Surgeries: Reconstructive, Plastic Surgery and Supplies
Required
Prior authorization
Yes, for the following: Plastic & reconstructive services (including implants after a mastectomy) to correct a physical disorder following an injury or incidental to covered surgery.
Yes, for the following: Plastic & reconstructive services (including implants after a mastectomy) to correct a physical disorder following an injury or incidental to covered surgery.
No, not covered
Surgeries: Rhinoplasty and Septoplasty Surgeries: Endovenous Laser, Radiofrequency Ablation (Varicose Vein Surgery)
Required
Prior authorization Prior authorization
Yes, must be determined medically necessary by the plan Yes, when determined medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, when determined medically necessary by the plan
Surgeries: Shoulder Replacement Surgery (Inpatient)
Required
Prior authorization
Yes, must be determined medically necessary by the plan
Yes, must be determined medically necessary by the plan
No, not covered
Surgeries: Hip Replacement Surgery Surgeries: Hysterectomy (abdominal, vaginal) Surgeries: Knee Arthroscopy
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered No, not covered No, not covered No, not covered
No, not covered
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Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Surgeries: Skin Tag Removal
No requirement when service is done by primary care provider
No requirement when service is done by primary care provider
Yes, however covered only when performed by the member’s assigned PCP
Yes, however covered only when performed by the member’s assigned PCP
No, not covered
Surgeries: Strabismus
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Surgeries: Tonsillectomy and Adenoidectomy
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes
Yes
No, not covered
Surgeries: UPP (Uvulopalatopharyngoplasty) Surgeries: Vasectomy
Required
Prior authorization If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, must be determined medically necessary by the plan No, not covered for members 20 and younger
No, not covered
Not required
Yes, must be determined medically necessary by the plan Yes, must be more than 21 y/o, sign consent form & wait 30 days after signature
Temporomandibular Joint (TMJ) & Myofacial Pain
Not required
If provider is participating then physician's order is required. If provider is not participating then plan approved referral is required.
Yes, medical treatment only. Dental services are not covered (see DSHS column for dental services). Some diagnostic tests may require a PA (e.g. MRI TMJ and surgical treatment).
Yes, medical treatment only. Dental services are not covered (see DSHS column for dental services). Some diagnostic tests may require a PA (e.g. MRI TMJ and surgical treatment).
Yes, for members less than 21 years old and those who do not meet other federal requirements. They must sign a consent form & wait 30 days after signature Yes, services provided by a dentist or that are billed with American Dental Assoc. codes are paid Fee‐For‐Service by DSHS.
Transplants: Corneal Transplant Transplants: Organ Donation, Tissue Donation & work-up related to Transplants (Excludes Corneal)
Hospital notification Required
Hospital notification
Yes
Yes
No, not covered
Prior authorization
Yes, transplants for: heart, kidney, liver, bone marrow, lung, heart‐lung, pancreas, kidney‐pancreas, cornea & peripheral blood stem cell.
Yes, transplants for: heart, kidney, liver, bone marrow, lung, heart‐lung, pancreas, kidney‐pancreas, cornea & peripheral blood stem cell.
No, not covered
Habilitative Services for HEX (Expansion/Alternative Benefit Plan Members only)
Not required
For HEX (expansion/alternative benefit plan members only)
Two follow-up prenatal genetic counseling encounters, billable for each 30 minutes up to 90 minutes per encounter, per pregnancy (within an 11-month period)
Ages 20 and younger, no limits to benefit
2015 CHPW Apple Health Benefit Grid
12/19/2014
Page 27
Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Transplants: Organ Donation or Tissue Donation (Excludes Corneal)
Required
Prior authorization
Yes, covered by CHP for donor’s initial medical expenses relating to harvesting of the organs as well as the costs of treating complications directly resulting from the procedures provided the organ recipient is a member of CHP. See additional info.
Yes, covered by CHP for donor’s initial medical expenses relating to harvesting of the organs as well as the costs of treating complications directly resulting from the procedures provided the organ recipient is a member of CHP. See additional info.
No, not covered
Transplants: Transplant Donor Search Transportation (from and to office visits) home to office or from PCP to specialist
Required
Prior authorization No, not covered
Yes, covered up to 15 searches per calendar year No, not covered
No, not covered
No, not covered
Yes, covered up to 15 searches per calendar year No, not covered
Urgent Care (urgently needed care)
Not required
There are no referral requirements for par/non-par urgent care providers
Yes
Yes
No, not covered
Vaccinations (see immunizations)
No, not covered (except shingles vaccination for over 60 years of age)
No, not covered
No, not covered
No, not covered
No, not covered
Vitamins
Not required
Prescription
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Injections: Belimumab (Benlysta®) Injections: Bevacizumab (Avastin®) Injections: Brentuximab (Adcetris®) Injections: Certolizumab (Cimzia®) Injections: Denosumab (Prolia® or Xgeva®)
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Required
Prior authorization
Yes, some are covered through the pharmacy benefit. Not covered if over the counter. Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Injections: Ranibizumab (Lucentis®) Injections: Trastuzumab (Herceptin®) Injections: Adalimumab (Humira®) Injections: Amifostine (Ethyol®)
Yes, some are covered through the pharmacy benefit. Not covered if over the counter. Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
2015 CHPW Apple Health Benefit Grid
12/19/2014
Contact a transportation broker in the respective county using the following resource. http://www.hca.wa.gov/medic aid/transportation/pages/pho ne.aspx
No, not covered No, not covered No, not covered No, not covered No, not covered No, not covered No, not covered No, not covered No, not covered
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Benefits of Service
Prior Authorization
Requirements
Adult Covered Services: Age 19 and Older Unless Otherwise Noted
Children Covered Services: Age 18 and Younger Unless Otherwise Noted
Fee-For-Service DSHS Coverage
Injections: Docetaxel (Taxotere®) Injections: Epoprostenol (Flolan) Injections: Golimumab (Simponi®) Injections: Granulocyte- colony stimulating factor (G-CSF) (Pegfilgrastim®) Injections: Pertuzumab (Perjeta) Inpatient (All Planned Admissions)
Required
Prior authorization Prior authorization
Required
Prior authorization
Required
Prior authorization
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan Yes, must be determined medically necessary by the plan
Required
Prior authorization Prior authorization (hospital notification required for all admits)
Yes, must be determined medically necessary by the plan Yes, when determined to be medically necessary by the plan
No, not covered
Required
Yes, must be determined medically necessary by the plan Yes, when determined to be medically necessary by the plan
Injections: Rilonacept (Arcalyst)
Required
Prior authorization
Yes, must be determined medically necessary by the plan
Yes, must be determined medically necessary by the plan
No, not covered
2015 CHPW Apple Health Benefit Grid
12/19/2014
No, not covered No, not covered No, not covered
No, not covered
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