2014 Apple Health Benefit Grid
BH+/BH S-Med/S-Chip
Benefits Of Service
Prior
Requirements
Authorization
Abortion, Spontaneous
(miscarriage)
Not required
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Member may self‐refer to
Yes
contracted women’s health
care providers. If provider is not
in network then plan approved
referral is required.
Yes
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
Alcohol and Substance
(See Chemical
Abuse Services, Inpatient, Dependency)
Outpatient, and
Detoxification
(See Chemical Dependency)
(See Chemical Dependency)
Must be provided by
Department of Social and
Health Services (DSHS)
certified agencies. Call
1-877-301-4557 for specific
information.
Allergy Injections
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered by DSHS.
Allergy Office Visit
Not Required
If provider is participating then Yes.
physician's order is required. If
provider is not participating
then plan approved referral is
required
Yes.
No, Not Covered by DSHS.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
(See Chemical Dependency)
Page 1
Benefits Of Service
Prior
Requirements
Authorization
Allergy Testing/ Serum
Not Required
If provider is participating then Yes
physician's order is required. If
provider is not participating
then plan approved referral is
required
Yes
No, Not Covered by DSHS.
Alternative Care:
Acupuncture
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Alternative Care:
Biofeedback Therapy
Not required
If provider is participating then Yes.
physician's order is required. If
provider is not participating
then plan approved referral is
required
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
Not Covered for member s 21 years Covered for children only (age 20 and
Chiropractor. If provider is
of age or older.
younger) with referral from PCP after
participating then a Physician's
well child screening.
order is required. If provider is
NOT participating then a Plan
Approved Referral is required
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/m
edicaid/billing/documents/
guides/chiropractic_service
s_bi.pdf
Alternative Care:
Homeopathy
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Alternative Care:
Hypnotherapy
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Alternative Care: Massage No, Not
Therapy
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
No, Not Covered
Page 2
Benefits Of Service
Prior
Requirements
Authorization
Alternative Care:
Naturopathic Physicians
(Naturopathy)
Not required
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
CHPW contracts with
Yes
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
Alternative Care:
Not required
Osteopathic Manipulative
Therapy
Provider must be participating, LIMITED benefit: Ten (10)
and a physician's order is
osteopathic manipulations per
required.
calendar year are covered by the
health plan, only when performed
by a plan Doctor of Osteopathy
(D.O.).
LIMITED benefit: Ten (10) osteopathic No, Not Covered by DSHS.
manipulations per calendar year are
covered by the health plan, only when
performed by a plan Doctor of
Osteopathy (D.O.).
Ambulance: Air
No, not
covered
No, not covered
No, not covered
No, not covered
Yes, covered by DSHS. Air
ambulance claims must be
submitted to DSHS.
Effective date: 05/01/2013.
Ambulance: Facility-ToFacility
Not required
Yes. Must be transportation to
a higher level care facility. Not
to a hospital providing an
equivalent or lower level of
care.
Yes
Yes
No, not covered by DSHS.
Ambulance: Ground
Not Required
No requirement (par/non-par)
Yes
Yes
No, not covered by DSHS.
(See Mental Health)
(See Mental Health)
(See Mental Health)
(See Mental Health)
Attention Deficit Disorder (See Mental
(See Mental Health)
Health)
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
No, Not Covered
Page 3
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Birth Control (See Family
Planning)
Birth Control
(See Family
Planning)
Birth Control (See Family
Planning)
Birth Control (See Family Planning)
Birth Control (See Family Planning)
Birth Control (See Family
Planning)
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
Birth Defects And
Congenital Anomalies:
Office Visits
Not Required
If provider is participating then Yes
physician's order is required. If
provider is not participating
then plan approved referral is
required
Yes
No, Not Covered by DSHS
Blood/Blood Component
Not Required
If provider is participating then Yes, Including but not limited to,
Yes, Including but not limited to,
physician's order is required. If synthetic factors, plasma
synthetic factors, plasma expanders,
provider is not participating
expanders, and their administration and their administration
then plan approved referral is
required
No, Not Covered by DSHS
Cardiac Rehabilitation
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
Chemical Dependency
(Alcohol and Drug):
Inpatient Treatment
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
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).
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):
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
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Page 4
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Chemical Dependency
No, Not
(Alcohol and Drug): Partial Covered
Hospitalization
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Chemical Dependency
(Alcohol and Drug):
Residential Treatment
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 Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Circumcision: Routine
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Cochlear Implants
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
Complications from NonCovered Service
Not Required
If provider is participating then Yes, excluded for a period of 90
Yes, excluded for a period of 90 days,
a Physician's order is required.If days starting the day after the DOS starting the day after the DOS of the
provider is NOT participating
of the non Covered Service.
non-covered Service
then a Plan Approved Referral
is required
No, Not Covered
Contraceptive Devices:
Injections
Not Required
Member may self‐refer to
Yes, Depo Provera™ and Mirena™
contracted women’s health
are covered.
care providers. If provider is not
in network then plan approved
referral is required.
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
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Yes, Depo Provera™ and Mirena™ are
covered.
Page 5
Benefits Of Service
Prior
Requirements
Authorization
Contraceptive Devices:
IUD
Not Required
Member may self‐refer to
Yes, cervical caps, diaphragms and
contracted women’s health
IUD’s are covered.
care providers. If provider is not
in network then plan approved
referral is required.
Yes, cervical caps, diaphragms and
IUD’s are covered.
Contraceptive Devices:
Over The Counter
Products
Not Required
Prescription
Yes, Condoms, gels, foams, and
creams
Yes, Condoms, gels, foams, and creams No, not covered by DSHS.
Contraceptive Devices:
Prescriptions & Implants
Not Required
Prescription
Yes, Birth control pills
Medroxyprogesterone
injection,Nuvaring™, Ortho‐Evra™
Yes, Birth control pills
Medroxyprogesterone
injection,Nuvaring™, Ortho‐Evra™
No, Not Covered
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: Accidental
Services
Not required
If provider is participating then Yes, when services are not
a physician's order is required. performed by a dentist or oral
If provider is NOT participating surgeon
then a plan approved referral is
required.
Yes, when services are not performed
by a dentist or oral surgeon
Yes, Dental care provided
by dentist and some
limited orthodontics.
Dental: Anesthesia
No, Not
Covered
No, Not Covered
No, Not Covered
Yes refer to the
Department of Aging and
Adult Services
206-341-7750
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
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
Page 6
Benefits Of Service
Prior
Requirements
Authorization
Dental: medically
Necessary Services
Not Required
If provider is participating then Yes, when services are not
a Physician's order is required.If performed by a dentist or oral
provider is NOT participating
surgeon.
then a Plan Approved Referral
is required
Yes, when services are not performed
by a dentist or oral surgeon
Yes, when services are
performed by a dentist or
oral surgeon.
Dental: Routine Services
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Yes, Limited Routine Dental
Services are covered as a
Fee-For-Service, refer to
DSHS
Developmental Disabilities (see
(see neurodevelopment
neurodevelop
treatment)
ment
Treatment)
(see neurodevelopment
Treatment)
(see neurodevelopment Treatment) (see neurodevelopment Treatment)
(see neurodevelopment
Treatment)
Dialysis (hemodialysis,
peritoneal, renal (kidney
failure)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan.
necessary by the Plan .
No, Not Covered
DME: Apnea Monitor
Not Required
If provider is participating then Yes, limited to three (3) months of
physician's order is required. If rentals
provider is not participating
then plan approved referral is
required
Yes, limited to three (3) months of
rentals
No, Not Covered
DME: Bra's Post Surgical
Not Required
If provider is participating then Yes, 2 bras covered post
physician's order is required. If mastectomy only
provider is not participating
then plan approved referral is
required
Yes, 2 bras covered post mastectomy
only
No, Not Covered
DME: Breast Pumps
Electric Purchase only.
Limit of 1 per client per
lifetime.
Required
If provider is participating then Yes
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
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.
Required
If provider is participating then Yes
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
Yes
No, not covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Page 7
Benefits Of Service
Prior
Requirements
Authorization
DME: Breast Pumps
Manual Purchase only.
Limit of 1 per client per
lifetime.
Not Required
If provider is participating then Yes
physician's order is required. If
provider is not participating
then plan approved referral is
required
DME: C-pap/Bi-Pap 2
month rental, autoTitration
Required
Prior Authorization
Yes, Must be determined medically Yes, must be determined medically
necessary
necessary by the Plan
No, Not Covered
DME: C-pap/Bi-pap
Purchase
Required
Prior Authorization
Yes, Must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
DME: Chest Compression
Devices
Required
Prior Authorization
Yes, Must be Determined Medically Yes, must be determined medically
Necessary by the Plan
necessary by the Plan
No, Not Covered
DME: Communication
Devices
Required
Prior Authorization is Required
Yes.
No, Not Covered
DME: Cough Stimulating
Devices
Not required
If provider is participating then Yes, Must be Determined Medically Yes, must be determined medically
a physician's order is required. Necessary by the Plan
necessary by the Plan
If provider is NOT participating
then a plan approved referral is
required.
No, Not Covered
DME: Diabetic Supplies
Not Required
Prescription
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
insulin dependent
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Yes, these supplies can be obtained
with prescription at a participating
pharmacy. See Fee-For-Service
DSHS Coverage for more
information
Yes
Yes.
Yes, these supplies can be obtained
with prescription at a participating
pharmacy. See Fee-For-Service DSHS
Coverage for more information
No, Not Covered
Page 8
Benefits Of Service
Prior
Requirements
Authorization
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 Yes, when determined medically
a Physician's order is required. necessary by the plan.
If provider is NOT participating
then a Plan Approved Referral
is required
Yes, when determined medically
necessary by the plan.
DME: Enteral Therapy
Formula
Required
Prior Authorization
Yes. Oral enteral nutrition is a covered No, Not Covered
service for members 20 years of age
and younger.
DME: Fracture Frames
PA for
purchase not
required. PA
for rental
required
If provider is participating then Yes
physician's order is required. If
provider is not participating
then plan approved referral is
required
Yes
No, Not Covered
DME: Hospital Bed
Required
Prior Authorization
Yes
Yes
No, Not Covered
DME: Humidifiers
Required
Prior Authorization
Yes
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, 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
No, Not Covered
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.
DME: Incontinent Supplies Not Required
(briefs, pull-ups, Liners)
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
No. Oral enteral nutrition is not
covered for members 21 years of
age and older.
Page 9
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
DME: Insulin Pump
Required
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan
Prior Authorization
No, Not Covered
DME: Lymphedema Sleeve Not Required
If provider is participating then Yes, covered as part of cancer
physician's order is required. If treatment
provider is not participating
then plan approved referral is
required
Yes, covered as part of cancer
treatment.
No, Not Covered
DME: Nebulizer
Not Required
If provider is participating then Yes, purchase only
physician's order is required. If
provider is not participating
then plan approved referral is
required
Yes, purchase only
No, Not Covered
DME: Oseogen (Bone
Growth Stimulator)
Required
Prior Authorization
Yes, Must be Determined Medically Yes, must be determined medically
Necessary by the Plan
necessary by the Plan
No, Not Covered
DME: Oxygen & Related
Equipment
Required
Prior Authorization
Yes, Must be Determined Medically Yes, must be determined medically
Necessary by the Plan
necessary by the Plan
No, Not Covered
DME: Patient Lifts
Not required
If provider is participating then Yes.
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
DME: Prenatal Therapy
and Supplies
Not Required
If provider is participating then Yes, Must be determined medically Yes, must be determined medically
a physician's order is required. necessary by the Plan
necessary by the Plan
If provider is NOT participating
then a plan approved referral is
required.
No, Not Covered
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
No, Not Covered
DME: Prosthetics and
May require
Orthotics (i.e, Prostheses, prior
Breast Implants)
authorization.
Check
Procedure
Codes for
more details.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Yes.
Yes
No, Not Covered
Page 10
Benefits Of Service
Prior
Requirements
Authorization
DME: Suction Pumps
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
DME: TENS Unit (Covered
under Medicare only)
No, not
covered
No, not covered
No, not covered
No, Not Covered
DME: Trapeze Bars
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
DME: Ventilators And
Related Equipment
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
DME: Wheelchairs,
Scooters
Required
Prior Authorization
Yes must be determined medically
necessary by the Plan
Yes, must be determined medically
necessary by the Plan
No, Not Covered
DME: Wound Vac
Required
Prior Authorization
Yes, Must be Determined Medically Yes, must be determined medically
Necessary by the Plan
necessary by the Plan
No, Not Covered
Drugs (see prescriptions,
Pharmacy
(see
prescriptions,
Pharmacy)
(see prescriptions, Pharmacy)
(see prescriptions, Pharmacy)
(see prescriptions, Pharmacy)
(see prescriptions,
Pharmacy)
Emergency Room Services Not Required
No Requirement
Yes
Yes
No, Not Covered
Enteral Therapy Pump
Rental
Required
Prior Authorization
Yes, must be determined medically Yes, Must be determined medically
necessary by the Plan(Prior
necessary by the Plan(Prior
Authorization)
Authorization)
No, Not Covered
Experimental /
Investigational Services
and Drugs
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
Eye Ball Polishing
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:38 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
No, not covered
Page 11
Benefits Of Service
Prior
Requirements
Authorization
Eye Exam: Medical
Condition (diagnose and
treated)
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Eye Exam: Routine
Not Required
members may self refer to
Yes, one every twenty-four months Yes, one every twelve months (20 and
contracted providers If provider (21 and Older)
Younger)
is not in network then plan
approved referral is required.
Yes, fabrication services &
associated fitting services
are 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 feefor-service provider. Refer
to DSHS.
Family Planning:
Contraception
(emergency)
Not Required
Prescription
Yes, at a Participating pharmacy.
Yes, at a participating pharmacy.
No, Not Covered
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
Clients enrolled in a
CHP newborn selection form within 60 Medicaid agency
days of child's birth to ensure eligibility 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
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Yes
No, Not Covered
Page 12
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Family Planning: Newborn Not Required
Care
Greater than 5 days in the
hospital requires a separate
Hospital Notification. Less than
5 days is covered under Mom's
Notification
Family Planning: Office
Visits
Member may self‐refer to
Yes.
contracted women’s health
care providers. If provider is not
in network then plan approved
referral is required.
Not Required
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Yes, However parent must fill out
the HP newborn selection form
within 60 days of child's birth to
ensure eligibility
Yes, However parent must fill out the Clients enrolled in a
HP newborn selection form within 60 Medicaid agency
days of child's birth to ensure eligibility 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
Yes.
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 13
Benefits Of Service
Prior
Requirements
Authorization
Family Planning:
Outpatient (includes
observations )
Not Required
Member may self‐refer to
Yes
contracted women’s health
care providers. If provider is not
in network then plan approved
referral is required.
Family Planning:
Sterilization for
Women(includes tubal
ligation)
Not Required
Members may self refer to
contracted providers. If
provider is not in network then
plan approved referral is
required.
Yes, must be older than 21 years of No, Not Covered
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.)
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.
Forensic Exam
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
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,
No, not covered
counseling and laboratory services,
when medically necessary for diagnosis
of a medical condition
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Yes
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 14
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Genetic Counseling and
Testing: Prenatal is Not a
Covered Benefit
No, not
covered
No, not covered
No, not covered
Habilitative Services For
HEX
(Expansion/Alternative
Benefit Plan Members
only)
Not required
For HEX (Expansion/Alternative • Two follow-up prenatal genetic
Benefit Plan Members only)
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
Health Education And
Wellness Programs:
Diabetic Education
Not Required
If provider is participating then Yes, up to six hours of diabetes
a Physician's order is required.If education/diabetes management
provider is NOT participating
per client, per calendar year.
then a Plan Approved Referral
is required
Yes, up to six hours of diabetes
education/diabetes management per
client, per calendar year.
Health Education And
Wellness Programs:
Nutritional Counseling
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then No, Not Covered
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Covered for clients under age 21 when No, Not Covered
medically necessary and referred by
the provider after an EPSDT screening
Health Education And
Wellness Programs:
Asthma Education
Not Required
If provider is participating then Yes, covered up to 6 combined
a Physician's order is required.If (group and/or individual) v visits
provider is NOT participating
per calendar year.
then a Plan Approved Referral
is required
Yes, covered up to 6 combined(group
and/or individual) v visits per calendar
year.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
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 follow-up
prenatal genetic counseling
encounters, billable for
each 30 minutes up to 90
minutes per encounter, per
pregnancy (within an 11month period).
No, Not Covered
No, Not Covered
Page 15
Benefits Of Service
Prior
Requirements
Authorization
Hearing Aid Devices
Not required
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
If provider is participating then No, Not Covered
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
Covered for clients under age 20. You
will need to use an Apple Health feefor-service provider.
Covered for clients under
age 21. You will need to
use an Apple Health feefor-service provider.
Hearing Exams (audiology) Not Required
If provider is participating then Yes, examinations to determine
a Physician's order is required.If hearing loss.
provider is NOT participating
then a Plan Approved Referral
is required
Yes, examinations to determine
hearing loss.
No, Not Covered
HIV/Aids- Screning
Not Required
You have a choice of going to a Yes
Family Planning clinic, the local
health department, or going to
your PCP for the screening.
Yes
Yes, if member self refers
to the public health
departments or family
planning clinics
Home Health Agency
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
Home Health Care
Required
Prior Authorization Is required
Yes must be determined medically
necessary by the Plan . Includes
Private duty Nursing per HRSA
Guidelines
Home Infusion Therapy
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan(Prior
Authorization)
No, Not Covered
Home intrauterine Activity No, Not
Monitoring (Fetal heart
Covered
Monitor)
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Home Phototherapy
Hyperbilirubinemia
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Hospice Care
Required
Prior Authorization
Yes, when determined to be medically No, Not Covered
necessary by the plan. Includes private
duty nursing per HRSA guidelines.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Yes, when determined to be
medically necessary by the plan.
Includes private duty nursing per
HRSA guidelines.
No, Not Covered
Yes must be determined medically
No, Not Covered
necessary by the Plan . Includes Private
duty Nursing per HRSA Guidelines
Page 16
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Hospital Care: Inpatient
Inpatient
hospital
notification all admits.
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.
Hospital Care: Outpatient
Surgery
May require
prior
authorization.
Check
Procedure
Codes for
more details.
HPV (Human papilloma
Virus) Test
Yes, prior authorization is required for
elective inpatient stays. Hospital
notification is required for all non‐
elective inpatient stays.
No, Not Covered
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Hyperbaric Oxygen
Pressurization
Required
Prior Authorization
Yes must be determined medically
necessary by the Plan
Yes, must be determined medically
necessary by the Plan
No, Not Covered
Immunizations
Not Required
No requirement when
administered by the PCP and
/or the Public health
department (par-only)
Yes
Yes
No, Not Covered
Immunizations:
Menactra®
(meningococcal vaccine)
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 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 or 18 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.
No member cost sharing
for preventive health
services.
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
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Page 17
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Immunizations: Pediatric
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Yes for children only: noncovered for adults
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: Shingles
(Herpes Zoster)
Only covered
for over 60
years of age
No requirement
Only covered for over 60 years of
age
No
No, not covered
Immunizations: Varicella
vaccine (Chicken Pox)
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Impotence Treatment
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Incarcerated Care
Required
Services to Inmates of
Yes, please see comments in the
Correctional Facilities: the
requirement field.
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
requirement field.
Yes, please see comments
in the requirement field.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Page 18
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
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.
Injections: Adalimumab
(Humira®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections:
Required
Alpha-1Proteinase
Inhibitor (Aralst Np,
Glassia,Prolastin, Zemaira)
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Injections: Amifostine
(Ethyol®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Belimumab
(Benlysta®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Bevacizumab
(Avastin®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Botulinum
toxin (Botox®/Myobloc®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Brentuximab
(Adcetris®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
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
Yes, when determined to be
medically necessary by the plan
Yes, when determined to be medically
necessary by the plan
No, not covered
Injections: Certolizumab
(Cimzia®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Denosumab
(Prolia® or Xgeva®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Docetaxel
(Taxotere®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, including but not limited to testing No, Not Covered
and treatment of infertility, sterility,
artificial insemination, sterilization,
reversal and in fertilization.
Yes, when determined to be medically
necessary by the plan
Page 19
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Injections: Ecallantide
(Kalbitor)
Required
Prior authorization
Yes, when determined to be
medically necessary by the plan
Injections: Epoprostenol
(Flolan)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Erythropoiesis - Required
Stimulating Agents
(Darbepoetin, Epoetin)
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Injections: Etanercept
(Enbrel®)
Prescription + ESI PA (if self
administered) Prior
authorization (only if member
is unable to self-administer)
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: GnRH Agonists Required
(e.g. Lupron)
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Injections: Golimumab
(Simponi®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Granulocytecolony stimulating factor
(G-CSF) (Pegfilgrastim®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Growth
Hormone (Somatropin®)
Required
Prescription + ESI PA (if self
administered) Prior
authorization (only if member
is unable to self-administer)
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Hyaluronic Acid Required
Derivatives (e.g. Synvisc,
Hyalgan)
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: Ibandronate
(Boniva)
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: Icatibant
Acetate (Firazyr)
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: Iloprost
(Ventavis®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Infliximab
(Remicade)
Required
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Required
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
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
Page 20
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Injections: Intravenous
Immunoglobulin
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Ipilimumab
(Yervoy)
Required
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Injections: Natalizumab
(Tysabri®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Omalizumab
(Xolair®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Palivizumab
(Synagis®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Panitumumab
(Vectibix)
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: 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
Injections: Pegloticase
(Krystexxa)
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: Pertuzumab
(Perjeta)
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: Ranibizumab
(Lucentis®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Rilonacept
(Arcalyst)
Required
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Injections: Rituximab
(Rituxan®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan.
necessary by the Plan.
No, Not Covered
Injections: Trastuzumab
(Herceptin®)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan
necessary by the Plan
No, Not Covered
Injections: Ustekinumab
(Stelara)
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
Inpatient (All Planned
Admissions)
Required
Prior authorization (hospital
notification required for all
admits)
Yes, when determined to be
medically necessary by the plan
Yes, when determined to be medically
necessary by the plan
No, not covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Yes, when determined to be medically
necessary by the plan
Yes, when determined to be medically
necessary by the plan
Page 21
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Interpreter Services
Not Required
No, except for administrative
issues only. Such as handling
member complaints and
appeals. (see DSHS Column for
additional services available)
No, except for administrative issues
only. Such as handling member
complaints and appeals. (see DSHS
Column for additional services
available)
IV Therapy: Home
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan.
necessary by the Plan.
No, Not Covered
IV Therapy: Outpatient
May require
prior
authorization.
Check
Procedure
Codes for
more details.
Prior Authorization
Yes
Yes
No, Not Covered
Learning Disabilities
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Lymphedema Treatment
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If prior authorization is not
Yes, when determined to be
required: If provider is
medically necessary by the plan
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
No, Not Covered
Mammogram: Diagnostic
Required
Prior Authorization
Yes
Yes
No, Not Covered
Mammogram: Screening
Not required
Members may self refer to
Yes
contracted providers. If
provider is not in network then
plan approved referral is
required.
Yes
No, Not Covered
Manipulation of Spine &
Extremities (see
Chiropractic)
(see
Chiropractic
care and
osteopathic
manipulation)
(see Chiropractic care and
osteopathic manipulation)
(see Chiropractic care and
osteopathic manipulation)
(see Chiropractic care and osteopathic (see Chiropractic care and
manipulation)
osteopathic manipulation)
Maternity Services:
Inpatient
Not Required
Hospital Notification
Yes
Yes
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, except for administrative issues
only. Such as handling member
complaints and appeals. (see DSHS
Column for additional services
available)
Yes, for medical
encounters & DSHS Fair
Hearings. Interpreter must
be certified w/DSHS.
No, Not Covered
Page 22
Benefits Of Service
Prior
Requirements
Authorization
Maternity Services:
Outpatient
Not required
Members may self refer to
Yes
contracted providers. If
provider is not in network then
plan approved referral is
required.
Yes
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
Maternity Support
Services
No, not
covered
No, not covered
No, not covered
Part of the First Steps
Program. Call
1-800-322-2588.
Medical Nutrition Therapy Not required
2014 CHPW Apple Health Benefit Grid
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
No, not covered
If provider is participating then No, Not Covered
a physician’s order is required.If
provider is NOT participating
then a plan approved referral is
required.
10/13/2014 3:13:39 PM
Medical Nutrition Therapy is covered
No, Not 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/docum
ents/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
Page 23
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted 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. In-patient
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.
Mental Health: Outpatient Not required
Treatment
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 health provider.
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/d
bhr/rsn.shtml
Methadone Treatment
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Yes, Covered by the
Division of Behavioural
Health and Recovery
(DBHR). Call
1-877-301-4557
Neurodevelopment
Therapy
Not required
If provider is participating then Yes
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
Yes
Covers the service through
Apple Health fee-forservice for children when
provided in an approved
neurodevelopmental
center. See
http://www.doh.wa.gov/C
FH/cshcn/docs/ndclistonw
eb.pdf.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Page 24
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Neuropsychological
Required
Testing (CPT 96116, 96118,
96119)
Prior authorization
Yes
Yes
No, Not Covered
Obesity Services
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Gastroplasty covered by
DSHS Fee‐For‐Service.
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 Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Orthoptic Therapy
No, Not
Covered
None, Not Covered
No, Not Covered.
Fee-for-service may cover
children.
Out Of Area Coverage: ER
Not Required
No Requirement (par / non-par) Yes
Yes
No, Not Covered
Out of Area Coverage:
Inpatient
Not Required
Hospital Notification
Yes
Yes
No, Not Covered
Out of Area Coverage:
Routine
No, Not
Covered
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
No, Not Covered
No Requirement (par / nonpart)
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
1-877-301-4557
Outpatient Diagnostic:
Not Required
Services, Procedures, And
Tests
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, Not Covered.
Page 25
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Outpatient Diagnostic:
Laboratory Services
Not Required
There are no referral
requirements for Par/Non-Par
providers
Yes
Outpatient Diagnostic:
Therapeutic Radiological
Service Mri CAT Scans PET
Scans, and X-Ray's
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then Yes, Pet Scans, Some MRI, MRA,and Yes, Pet Scans, Some MRI, MRA, and
a Physician's order is required.If CT Angiography require a Prior
CT Angiography require a Prior
provider is NOT participating
Authorization.
Authorization.
then a Plan Approved Referral
is required
No, Not Covered
Over the counter
medications
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Pain Clinic: Alternative
Care
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Pain Clinic: Treatment
(e.g. nerve block,
epidural)
May require
prior
authorization,
check
procedure
code for
details.
If provider is participating then Yes, when determined to be
a Physician's order is required.If medically necessary by the plan
provider is NOT participating
then a Plan Approved Referral
is required
Yes, when determined to be medically
necessary by the plan
No, Not Covered
Pain Clinic: Office Visits
Not Required
If provider is participating then Yes, when determined to be
a Physician's order is required.If medically necessary by the plan
provider is NOT participating
then a Plan Approved Referral
is required
Yes, when determined to be medically
necessary by the plan
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
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
1-877-301-4557
Page 26
Benefits Of Service
Prior
Requirements
Authorization
Pain Clinic: Outpatient
Rehabilitation
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If prior authorization is not
Yes, when determined to be
required: If provider is
medically necessary by the plan
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
No, Not Covered
Pain Management
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Palliative Care
Required
Prior Authorization
Yes, covered in conjunction with
hospice and must be determined
medically necessary by the Plan.
Yes, covered in conjunction with
hospice and must be determined
medically necessary by the Plan.
No, Not Covered
Pathology Services
Not Required
No Requirement needed
(par/Non-Par)
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
1-877-301-4557
Physical Exams
Not Required
No Requirement when done by Yes
the PCP
Yes
No, Not Covered
PKU (Phenylketonuria)
Formula
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
PKU (Phenylketonuria)
Screening
No, Not
Covered
No, Not Covered
No, Not Covered
Yes, DSHS will reimburse
hospitals for newborn
screenings for PKU and
other metabolic disorders
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
No, Not Covered
Page 27
Benefits Of Service
Prior
Requirements
Authorization
Podiatry (including
diabetic foot care)
Not Required
Routine care not covered. See Yes
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
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.
Prescriptions, Pharmacy:
Mail Order Prescriptions
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
No, Not Covered
Prescriptions, Pharmacy:
Out of Area Drugs
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 No, Not Covered
when out of the service area and filled
at a participating pharmacy.
Prescriptions, Pharmacy:
Outpatient Drugs
May require
prior
authorization.
Check
Procedure
Codes for
more details.
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:
Take Home Drugs
Not Required
No, must be obtained with a
prescription at a participating
pharmacy.
No, must be obtained with a
prescription at a participating
pharmacy.
N0, must be obtained with a
prescription at a participating
pharmacy.
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Page 28
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Preventive Care
Not Required
No requirement when done by
the PCP
Yes, including but not limited to
immunizations, well‐child checks,
screening colonoscopies,
mammograms and bone density
testing.
Yes, including but not limited to
immunizations, well‐child checks,
screening colonoscopies,
mammograms and bone density
testing.
No, Not Covered
Psychiatric Care, InNo, not
patient and Crisis Services covered
(See Mental Health for
more information).
No, not covered
No, not covered
No, not covered
All mental health services
when received from a
community mental health
agency. In-patient
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.
Pulmonary Rehabilitation
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not covered
No, Not Covered
Radiation &
Chemotherapy
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then Yes, some agents require Prior
a Physician's order is required.If Authorization
provider is NOT participating
then a Plan Approved Referral
is required
Yes, some agents require PA
No, Not Covered
Radiation &
chemotherapy: Injectable
And Infused
Chemotherapy
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then Yes, some agents require Prior
a Physician's order is required.If Authorization.
provider is NOT participating
then a Plan Approved Referral
is required
Yes, some agents require Prior
Authorization.
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Page 29
Benefits Of Service
Prior
Requirements
Authorization
Radiation &
Chemotherapy: Oral
Chemotherapy
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then Yes, some agents require Prior
a Physician's order is required.If Authorization.
provider is NOT participating
then a Plan Approved Referral
is required
Yes, some agents require Prior
Authorization.
No, Not Covered
Rehabilitation: Inpatient
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
Rehabilitation: Outpatient See Covered
Occupational Therapy
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
For Members 21 Years of Age And
Older: Initial evaluation, reevaluation 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 See Covered
Physical Therapy
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
For Members 21 Years of Age And
Older: Initial evaluation, reevaluation 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 See Covered
Speech Therapy
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
For Members 21 Years of Age And
Older: Initial evaluation, reevaluation 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
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Page 30
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Respite Care (hospice)
(please see hospital Care)
(please see
hospital Care)
(please see hospital Care)
(please see hospital Care)
(please see hospital Care)
(please see hospital Care)
Reversal of Sterilization
No, Not
Covered
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, Covered for Health
Options Members by DSHS
FFS
Saliva Testing
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
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)
Not Required
No Requirement (par/non‐par) Yes
Yes
No, Not Covered
Screening Exams:
(preventive) Colorectal
(colonoscopy)
Not Required
if provider is participating then Yes, screening and diagnostic
a Physician's order is required.If colonoscopies are covered.
provider is NOT participating
then a Plan Approved Referral
is required
Yes, screening and diagnostic
colonoscopies are covered.
No, Not Covered
Screening, Brief
Not required
Intervention, Referral and
Treatment (SBIRT)
SBIRT 1 screening and 4 brief
Yes, when client is age 18 or older
interventions so total of 5 units
for these two codes (99408 &
99409) per year
Not covered for members younger
than 17
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
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 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.
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Page 31
Benefits Of Service
Prior
Requirements
Authorization
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 Yes, covered for obstructive sleep
a Physician's order is required.If apnea and narcolepsy diagnoses
provider is NOT participating
only.
then a Plan Approved Referral
is required
Yes, covered for obstructive sleep
apnea and narcolepsy diagnoses only.
No, Not Covered
Smoking and Tobacco
Cessation: Drugs
Not Required
Prescription
Yes
Yes
No, Not Covered Not
covered by DSHS.
Smoking and Tobacco
Cessation: Nicotine
Replacement
Not Required
Prescription
Yes, some may be covered
Yes, some may be covered
No, Not Covered
Smoking and Tobacco
Cessation: Services
Not Required
If the provider is participating
then a physician's order is
required. If the provider is not
participating then a plan
approved referral is required
Yes, Ages 18 and older are covered Not covered for members younger
through Alere Quit-for-Life smoking than 18.
cessation program. For questions,
please call 1-866-784-8454.
No, Not Covered
Substance Abuse (see
Chemical Dependency)
(see Chemical
Dependency)
(see Chemical Dependency)
(see Chemical Dependency)
(see Chemical
Dependency)
Surgeries: Knee
Arthroscopy
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Shoulder
Arthroscopy
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Abortion,
Voluntary
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
(see Chemical Dependency)
No, Not Covered
Page 32
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Surgeries: Ambulatory
Surgery (outpatient or
same day surgery)
May require
prior
authorization.
Check
Procedure
Codes for
more details.
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 additionalformation.
No, Not Covered
Surgeries: Bariatric
Surgery/ Weight Loss
Procedures
Not Covered
Prior Authorization Fee- for Service only
Fee- for -Service only
Fee- for -Service only
Must be approved by the
HCA Apple Health fee-forservice program.
Authorization for the 3stage bariatric surgery only
when medically necessary.
Surgeries: Blepharoplasty
(Eyelid Surgery)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan.
No, Not Covered
Surgeries: Breast
Reduction Surgery
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan.
necessary by the Plan.
No, Not Covered
Surgeries: Cosmetic or
Plastic Surgery. Including
tattoo removal, face lifts,
ear or body
No, Not
Covered (See
Additional
Information
column)
No, Not Covered (See
No, Not Covered (See Additional
Additional Information column) Information column)
No, Not Covered (See Additional
Information column)
No, Not Covered (See
Additional Information
column)
Surgeries: Endovenous
Laser, Radiofrequency
Ablation (Varicose Vein
Surgery)
Required
Prior Authorization
Yes, when determined medically
necessary by the Plan .
Yes, when determined medically
necessary by the Plan .
No, Not Covered
Surgeries: Eye Surgery
(laser) (for a medical
condition)
May require
prior
authorization.
Check
Procedure
Codes for
more details.
If provider is participating then
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes, surgeries for a medical
Yes, surgeries for a medical condition
condition such as glaucoma, retinal such as glaucoma, retinal detachment
detachment and cataracts are
and cataracts are covered.
covered.
No, Not Covered
Surgeries: Eye Surgery
(Lasik®)(for vision
improvement)
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, Not Covered
Page 33
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Surgeries: Hip
Replacement Surgery
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Hysterectomy
(abdominal, vaginal)
Required
Prior authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Knee
Replacement Surgery
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Mammoplasty
May require
prior
authorization.
Check
Procedure
Codes for
more details.
Prior authorization
Yes, initial reconstruction
mammoplasty is covered regardless
of whether the member was
covered by CHP at the time of
theoriginal mastectomy. ( see extra
information for more info.)
Surgeries: Mastectomy
Not Required
If procedure is performed in an Yes
inpatient setting then a
Hospital Notification is
required. If procedure is
outpatient and theprovider 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
Surgeries: Reconstructive, Required
Plastic Surgery and
Supplies
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 &
No, Not Covered
reconstructive services (including
implants after a mastectomy) To
correct a physical disorder following an
injury or incidental to covered surgery
Surgeries: Rhinoplasty and Required
Septoplasty
Prior authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Sclerotherapy
(Varicose Veins)
Required
Prior authorization
Yes, when determined to be
medically necessary by the plan
No, not covered
Surgeries: Shoulder
Replacement Surgery
(Inpatient)
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
Yes, initial reconstruction
No, Not Covered
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)
Yes, when determined to be medically
necessary by the plan
No, Not Covered
No, Not Covered
Page 34
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Surgeries: Skin Tag
Removal
No
No requirement when service is Yes, however covered only when
requirement
done by primary care provider. performed by the member’s
when service is
assigned PCP.
done by
primary care
provider.
Yes, however covered only when
performed by the member’s assigned
PCP.
No, Not Covered
Surgeries: Spinal
Required
Prior authorization
Yes, when determined to be medically
necessary by the plan
No, not covered
Surgeries: Strabismus
Not Required
If provider is participating then Yes
a Physician's order is required.If
provider is NOT participating
then a Plan Approved Referral
is required
Yes
No, Not Covered
Surgeries: Tonsillectomy
and Adenoidectomy
Not Required
If Provider is Participating then Yes
Physician's order is Required. If
Provider is Not Participating
then a Plan Approved Referral
is Required.
Yes
No, Not Covered
Yes, when determined to be
medically necessary by the plan
Surgeries: UPP
Required
(Uvulopalatopharyngoplas
ty)
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan .
No, Not Covered
Surgeries: Urethral
Suspension
Required
Prior Authorization
Yes, must be determined medically Yes, must be determined medically
necessary by the Plan .
necessary by the Plan.
No, Not Covered
Surgeries: Vasectomy
Not Required
If provider is participating then Yes, must be more than 21 y/o, sign No, Not Covered For members 20 and
a Physician's order is required.If consent form & wait 30 days after younger.
provider is NOT participating
signature.
then a Plan Approved Referral
is required
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.
If provider is participating then
a physician's order is required.
If provider is NOT participating
then a plan approved referral is
required.
Yes, services provided by a
dentist or that are billed
with American Dental
Assoc. codes are paid Fee‐
For‐Service by DSHS.
Temporomandibular Joint Not required
(TMJ) & Myofacial Pain
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
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 )
Page 35
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Transplants: Corneal
Transplant
Hospital
Notification
Hospital Notification
Yes
Yes
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 organ's as well as
the costs of treating complications
directly resulting from the
procedure's provided the organ
recipient is a member of CHP. See
additional info
Yes, covered by CHP for donor’s initial No, Not Covered
medical expenses relating to
harvesting of the organ's as well as the
costs of treating complications directly
resulting from the procedure's
provided the organ recipient is a
member of CHP. See addition info for
ext
Transplants: Organ
Required
Donation, Tissue Donation
& work-up related to
Transplants (Excludes
Corneal)
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
Transplants: Transplant
Donor Search
Required
Prior Authorization
Yes, covered up to 15 searches per
calendar year.
Yes, covered up to 15 searches per
calendar year.
No, Not Covered
Transportation (from and
to office visits) home to
office or from PCP to
specialist
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Contact a transportation
broker in the respective
county using the following
resource.
http://www.hca.wa.gov/m
edicaid/transportation/pag
es/phone.aspx
Unlisted Codes with
Charge > $1,000.00
Required
Required
Required
Required
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
No, Not Covered
covered
(except
shingles
vaccination for
over 60 years
of age)
No, Not Covered
No, Not Covered
No, Not Covered
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, Not Covered
Page 36
Benefits Of Service
Prior
Requirements
Authorization
Adult Covered Services: Age 19
Children Covered Services: Age 18
Fee-For-Service DSHS
and Older Unless Otherwise Noted and Younger Unless Otherwise Noted Coverage
Vaccinations Shingles
Only covered
for over 60
years of age
No requirement
Only covered for over 60 years of
age
No
No, not covered
Vision Services (See Eye
Exam)
See Eye Exam
See Eye Exam
See Eye Exam
See Eye Exam
See Eye Exam
Vitamins
Not Required
Prescription
Yes, some are covered through the
pharmacy benefit. Not covered if
over the counter
Yes, some are covered through the
pharmacy benefit. Not covered if over
the counter
No, Not Covered
Vitamins: B12 Injections
Not Required
If Provider is Participating in
Yes
Network than Physican's Order
is Required. If Provider is Not In
NetworkPlan Approved Refferal
Is Required.
Yes
No, Not Covered
Vocational Rehabilitation
No, Not
Covered
No, Not Covered
No, Not Covered
No, Not Covered
Wound Care: Outpatient
Not Required
If provider is participating then Yes, more than 4 specialty visits per Yes, more than 4 specialty visits per
a Physician's order is required.If provider for each calendar year will provider for each calendar year will
provider is NOT participating
require a prior authorization.
require a prior authorization.
then a Plan Approved Referral
is required
2014 CHPW Apple Health Benefit Grid
10/13/2014 3:13:39 PM
No, Not Covered
No, Not Covered
Page 37