Master list of covered services

Copay Requirements and Exemptions

Issue Date Service
12/27/2017 Ambulance (emergency only)
12/27/2017 Ambulatory Surgical Center
12/27/2017 Behavioral Health Services
12/27/2017 Dental
12/27/2017 Durable Medical Equipment (DME)
12/27/2017 Hearing Aid
12/27/2017 Home Health
12/27/2017 Hospice
12/27/2017 Hospital
04/06/2018 Long Term Care
12/27/2017 Non-Emergency Medical Transportation (NEMT)
12/27/2017 Optical
12/27/2017 Personal Care
12/27/2017 Pharmacy
12/27/2017 Physicians and Clinics
12/27/2017 Private Duty Nursing
12/27/2017 Therapies – Occupational, Physical, and Speech