Mandatory Passages and Language for MC+ Managed Care Health Plan Handbook, page 11
Getting Medical Care
Call your Primary Care Provider (PCP) when you need health care. Your PCP's phone number is on your MC+ Managed Care health plan card. Your PCP will help you get the care you need or refer you to a specialist.
These services do not need a PCP referral:
- Birth control or family planning - you may go to our providers or an MC+ approved provider. We will pay for this care, even if the provider is not in [NAME OF PLAN].
- Mental health care - you may go to any of our mental health providers. Just call this toll free number [PLAN PHONE NUMBER].
- Local public health agencies - Children may go to local public health agencies for shots. Members may go to local public health agencies for tests and treatment of sexually transmitted diseases and tuberculosis; HIV/AIDS tests; or for lead poisoning screening, testing and treatment.
- Women's health service - You may go to any of our GYN providers.
- NOTE: Plan must add any other services that do not require PCP referral: (i.e. dental, vision and others) with phone numbers.
You may have to pay for services you get if:
- you go to another health care provider without a referral from your PCP; or
- you choose to get medical services that are not covered by MC+ Managed Care.
- you go to a provider that is not a health plan provider without prior approval.
- you do not have prior approval for services that need it.
Health Care Away From Home
- If you need urgent health care when you are away from home, call your PCP or your health plan for help
- In an emergency, you do not need to call your PCP first. Go to the nearest emergency room or call 911.
- Call your PCP after an emergency room visit.
- Get your follow up care from your PCP.
- Routine health care services must be received from your PCP when you get back home.
- All services outside the United States and its Territories are not covered.
Pharmacy Dispensing Fees
Pharmacy Dispensing Fees - Children under 19 do not have to pay a pharmacy dispensing fee. Members nineteen (19) and older pay a pharmacy dispensing fee for each drug they get. This fee is $0.50 up to $2.00 for each drug. The amount of this fee is based on the cost of the drug. You should never pay a fee of more than $2.00 for each drug. Remember, if you get more than one drug at the same time, you will pay these fees for each drug you get.
You will not pay a dispensing fee when the medicine is for an emergency, family planning, a foster child, EPSDT/HCY services, or a pregnancy related reason.
To ask what you have to pay call [NAME OF PLAN] Member Services at your MC+ Managed Care health plan.
