Part 2: Your GA-U Benefits
- Services Covered by Community Health Plan
- Services Covered by DSHS or Other Programs
- Services at Your Local Health Department
- Services Not Covered by Community Health Plan, DSHS, or Other Program
- Payments for Services Not Covered by Community Health Plan, DSHS, or Other Programs
- About Prior Authorizations and Referrals
Download Benefits section as PDF
Download Prior Authorizations and Referrals section as PDF
Download Payments section as PDF
This section is a summary of services and treatments covered by Community Health Plan and the Washington State Department of Social and Health Services (DSHS) for GA-U. Some health care services are not covered by GA-U.
Sections include:
- Services Covered by Community Health Plan lists benefits offered by the Plan when they are medically necessary. (For more information, see Medically Necessary.) The "Details" column gives more information about the benefit itself, including whether it requires an approval, such as prior authorization.
- Services Covered by DSHS or Other Programs lists services offered by DSHS or other agencies and programs when they are medically necessary.
- Services at Your Local Health Department lists services offered by your local Washington State Department of Health office when they are medically necessary. You must show your DSHS Services card to get these services. For more information, please call DSHS at 1-800-562-3022.
- Services Not Covered by Community Health Plan, DSHS, or Other Program lists services and treatments that are not covered on your GA-U program.
If you have a question about a specific service, call the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
- For more information about prior authorizations and approvals, see About Prior Authorizations and Referrals.
- For more information about what "medically necessary" means, see Medically Necessary.
- For details of which services are offered by Community Health Plan:
- Contact your provider or other clinic staff.
- Call the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
Important notes:
- The information in this book is accurate at the time it was posted. To make sure you have the most current information, contact the sources listed under More information.
- All services and treatment are covered only if medically necessary. For more information, see Medically Necessary.
- You will need a referral from your PCP and often an authorization from Community Health Plan before you get a service or treatment. If you get a service before you get an authorization or referral, you might have to pay for it yourself.
- Professional services are covered by Community Health Plan. Facility services are covered by DSHS.
Services Covered by Community Health Plan
Note: If you do not find a service listed in this table, please check the lists that follow it:
- Services Covered by DSHS or Other Programs
- Services at Your Local Health Department
- Services Not Covered by Community Health Plan, DSHS, or Other Program
Benefit |
Details |
Ambulance transportation for emergency medical conditions |
For non-emergency conditions transportation is covered if any of the following is true:
|
Anesthesia |
|
Antiretroviral agents |
|
Blood and blood products |
|
Cardiac rehabilitation |
Requires prior authorization. |
Chemotherapy, oral and injectable or infused |
Some agents require prior authorization. Check before getting the treatment. |
Circumcision only to treat underlying medical condition |
|
Diagnostic procedures and tests, including laboratory |
Covered by DSHS or by Community Health Plan, or by both, depending on the specific procedure or test. |
| Durable medical equipment | Not a covered benefit. However, in very limited cases your provider may work with Community Health Plan to get a prior authorization. |
Emergency services, including post-emergency follow-up in a clinic or hospital. (For more information, Emergency Care.) |
Emergency service is covered when:
|
Eye exams |
An eye exam is covered once in a 24-month period. Eye care services for medical conditions are not limited. Frames are paid for by DSHS. |
Growth hormone therapy injections |
Requires prior authorization:
|
Health education for asthma, diabetes, and heart disease |
Up to 6 visits per calendar year. Requires prior authorization. |
Home health services through state-licensed agencies |
Requires prior authorization. |
Home infusion therapy |
Requires prior authorization. |
Hospital care: some outpatient surgery, including emergency room and outpatient services |
Outpatient surgery requires prior authorization |
HPV test |
|
Immunizations, including but not limited to:
|
|
Injections including but not limited to:
|
If self administered, requires prescription and a prior authorization from Express Scripts, Inc. (ESI), the Community Health Plan pharmacy benefit manager. Requires Community Health Plan prior authorization if the patient cannot self administer. |
IV therapy, home or outpatient |
Requires prior authorization. |
Laboratory diagnostic tests |
Covered by DSHS or by Community Health Plan, or by both, depending on the specific test. |
Lymphedema treatment |
Requires prior authorization for more than 12 visits per year. Covered by DSHS or by Community Health Plan. |
Mammogram |
When done in a free-standing imaging center. |
Mental health services, including:
|
Requires a referral from your primary care provider to the care coordinator at the primary care clinic. |
Neuropsychological testing |
Requires prior authorization for more than 12 visits per year. |
Office visits with providers such as physicians, physician assistants, registered nurses (RNs), advanced registered nurse practitioners (ARNPs), podiatrists, audiologists, and certified dietitians. |
Requires prior authorization for more than 12 visits per year. |
Orthoptic (eye training) care for eye conditions |
|
Osteopathic manipulation |
Requires prior authorization for more than 10 visits per year. |
Pain treatment, including office visits, outpatient rehabilitation, treatment (nerve block, epidural, steroid injection) |
Requires prior authorization for more than 12 visits per year. |
Pharmacy and prescriptions (outpatient) |
Only drugs on the Community Health Plan Formulary are covered. (For more information about your pharmacy benefit, see Prescription Drug Services.) |
Physical, occupational, and speech therapy |
Requires prior authorization for more than 12 visits per year. |
Podiatry, including diabetic foot care |
|
Preventive care, such as immunizations, screening colonoscopies, mammograms, bone density testing |
|
Radiation treatment |
Some agents require prior authorization. Check before getting the treatment. |
Radiology (including PET scans, some MRI and MRA, CT-head, and CT angiography), nuclear medicine, ultrasound, laboratory, other diagnostic services, including x-rays, ultrasounds, echos |
All MRI imaging requires a prior authorization. |
Rehabilitation, inpatient and outpatient. |
|
Sexually transmitted disease treatment and follow-up care |
Covered by DSHS or by Community Health Plan, or by both. |
Skilled nursing facility |
Requires prior authorization from your PCP and also a referral from your Community Health Plan case manager. |
Sleep study for obstructive sleep apnea and narcolepsy diagnosis only |
|
Smoking cessation: Prescribed drugs and some nicotine replacement |
|
Specialty care, when referred by your PCP |
|
Surgeries including, but not limited to:
|
Some surgeries require prior authorization. Check before getting the treatment. |
Urgent care, including post-emergency follow-up. |
Urgent care is covered when:
|
Wound care, home health agency |
Requires prior authorization. |
Wound care, outpatient |
Requires prior authorization for more than 12 visits per year. |
Services Covered by DSHS or Other Programs
The services listed in this section are paid for by DSHS or other programs. You must use providers who will take your DSHS Services card. Your provider will know how to bill for payment. These services are paid by DSHS or another program, but they will be coordinated by your PCP and Community Health Plan.
- Chemical dependency detoxification, inpatient treatment, outpatient counseling
- Convalescent or custodial care
- Certain dental care (accidental or routine)
- Eyeglass frames, lenses, and fitting services
- Hearing aid
- Interpreter services for medical visits
- Maternity care & delivery, services, or maternity support/infant case management. (GA-U members who become pregnant are disenrolled from Community Health Plan and will receive their care through DSHS.)
- Mental health services, including:
- 24-hour crisis intervention
- Emergency mental health services
- Inpatient psychiatric care
- Methadone treatment for addiction
- Nursing facilities through Aging and Disability Services
- Protease inhibitors
- Sterilizations when younger than 21 years old
- Substance abuse treatment covered by the Division of Behavioral Health and Recovery (DBHR)
- Vocational rehabilitation
- Voluntary pregnancy termination
Services at Your Local Health Department
As a member of Community Health Plan, you can get the services listed in this section from Community Health Plan providers or you can go directly to a local health department or family planning clinic. You must use providers who will take your DSHS Medical Services card and find a provider who will bill DSHS for payment.
Services you can get at your local health department:
- Family planning services and birth control
- HIV and AIDS testing
- Immunizations
(For more information, see Adult Immunizations .) - Sexually transmitted disease treatment and follow-up care
- TB screening and follow-up care
Services Not Covered by Community Health Plan, DSHS, or Other Program
- Acupuncture
- Adult day health
- Biofeedback therapy
- Childbirth classes
- Chiropractic care for adults
- Cosmetic surgery and services
- Court-ordered services
- Doula services
- Experimental and investigational treatment or services.
These are health care services that Community Health Plan believes are not generally as effective, or have not been scientifically proven to be effective, for a particular disease or condition. They are not covered until good research shows they are more helpful than harmful. Community Health Plan looks at requests for experimental or investigational procedures on a case-by-case basis. - Gender dysphoria or sex reassignment surgery
- Homeopathy
- Hospice care
- Hypnotherapy
- Immunizations for international travel
- Lasik eye surgery to correct vision
- Massage therapy
- Medical exams for Social Security Disability benefits
- Medical services while in jail, beginning when a law enforcement officer takes the member into custody
- Naturopathy
- Out-of-country (outside of the United States) and outside of Washington state care
- Personal comfort items while in the hospital, such as telephone charges and TV
- Pharmacy: mail order prescriptions, take home drugs prescribed by hospital
- Physical exams needed for employment, immigration, insurance, or licensing
- Plastic surgery for cosmetic reasons
- Reversal of voluntary surgical sterilizations
- Services not allowed by federal or state law
- Sexual dysfunction treatment, including impotence treatment; penile prosthesis; diagnosis and treatment of infertility, impotence, and sexual dysfunction
- Sports physicals
- TMJ treatment, including medical and surgical treatment and appliances
- Zostavax (shingles) immunization
Payments for Services Not Covered by Community Health Plan, DSHS, or Other Programs
You do not have to pay for covered services.
You might have to pay if you decide to get care outside of the Community Health Plan network of providers without prior, written Community Health Plan permission.
You also might have to pay if you get treatment or services not covered by GA-U, Community Health Plan, DSHS, or other programs.
Community Health Plan does not pay for services you get outside Washington State.
If you have any questions, please call the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.
Third-Party Liability
Community Health Plan will decide whether or how to pay for accident-related medical bills. If it appears that another insurance company should pay, we will get payment from that company for any payments we made. If you get a settlement, you may need to refund Community Health Plan for any bills we have paid related to the accident.
If you were hurt while at work, your medical bills will be paid by workers' compensation. You must tell your PCP and Community Health Plan about your injury right away.
Your workers' compensation will cover all your injury-related bills. If the injury is not work related, Community Health Plan will pay all related covered expenses after we get a denial letter from your workers' compensation plan.
Coordination of Benefits (COB) and Third-Party Liability (Subrogation)
Coordination of benefits happens when you are covered by more than one health insurance plan at the same time.
If you have two insurance plans, call the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.
You should also call the Medical Assistance customer service center at 1-800-562-3022 to tell them you have other insurance. The other insurance plan must pay first for all the medical care it covers. Community Health Plan will then pay for the remaining covered charges.
Third-party liability (subrogation) is when there is another company that pays for health care services you get because of an injury or illness. For example, your auto insurance may pay if you are injured in a car accident, or workers' compensation may pay if you are hurt on the job. This is different than COB, because the third party will only pay for the services that are related to that injury or illness.
If another company should pay for your medical bills, please call the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.
About Prior Authorizations and Referrals
Community Health Plan is a managed care health plan. This means that your primary care provider (PCP) and the Plan coordinate all of your care. You need to get services and drugs from your PCP or another provider in our network.
A referral from your PCP is not the same as a prior authorization. For more information and to avoid charges you might have to pay for yourself, please see What is a Referral? and What is a Prior Authorization?
To find a provider or pharmacy in our network:
- See the 2010 Community Health Plan Provider and Pharmacy Directory.
- Visit the Provider Directory Search online, which is updated as provider lists change.
- Phone the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
For some services and drugs you need to get a prior authorization. You may also need a referral from your PCP to see some other providers.
Important notes:
- In most cases, if Community Health Plan does not approve a referral to a provider outside our network before you see the provider, the Plan will not pay for the service.
- If you get a service on the Prior Authorization List without getting the authorization first, the Plan will not pay for it. This may include other services related to a service you got that was not authorized.
- Sometimes the prior authorization list changes during a calendar year. To make sure you have the most current list of what requires approval before the service and to avoid charges you don't expect, always ask your PCP or call our customer service team before you get a service. Please phone the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
Most specialist services are covered by your plan. Talk to your PCP, who may submit a referral to an in-network provider or submit a referral to an out-of-network provider if an in network provider is not available. Some services, whether from an in-network or out-of-network provider, require a prior authorization as well.
The Prior Authorization List provides a guideline to which services and drugs require a prior authorization. For additional information, see Your GA-U Benefits.
What Is a Referral?
A referral is when one provider sends a patient to another provider, usually a specialist, for diagnosis and treatment. Before you see a specialist or another provider, talk to your primary care provider.
A referral is good only until the end of the period okayed by Community Health Plan.
If you have a complicated or serious medical problem, you have the right to a referral that lasts for a longer period of time than a regular referral. This is called an extended (or standing) referral. An extended referral, like a regular referral, is good only until the end of the period okayed by Community Health Plan.
To get a referral, you must talk to your PCP. Your PCP will tell us:
- Which provider the PCP refers you to.
- The length of time and number of visits your PCP says you may use the provider's services.
When Do I Need to Get a Referral?
Except in emergency care, if you get services or treatment from a provider outside our network without first getting a referral from your PCP, the Plan will not pay for it.
To find a provider or pharmacy in our network:
- See the 2010 Community Health Plan Provider and Pharmacy Directory.
- Visit the Provider Directory Search online, which is updated as provider lists change.
- Phone the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
You do not need your PCP's referral for:
- Emergency services, which also do not require prior authorization.
- Routine and preventive women's health care services by providers in the Community Health Plan network, regardless of diagnoses.
- Routine eye care once every 24 months.
- Family planning services and sexually transmitted disease screening and treatment services provided at family planning facilities such as Planned Parenthood or your local Public Health Department.
- Immunizations provided by your local Public Health Department.
- HIV screening and tuberculosis screening and follow-up at your local Public Health Department.
For more information about your benefits, see Your GA-U Benefits.
What Is a Prior Authorization?
Community Health Plan must approve some services before the service is provided. Community Health Plan must also approve some drugs before you get them.
A prior authorization is an approval by Community Health Plan of a procedure or other service on the Prior Authorization List. The Plan decides whether these procedures or services meet the standard of medical necessity. (For more information about medical necessity standards, see Medically Necessary.) If you get such a procedure or service without a prior authorization from the Plan, the Plan might not pay for it.
When Do I Need to Get a Prior Authorization?
You will need an authorization by Community Health Plan before you get the services listed in the Prior Authorization List. If you get a treatment that is not covered or get a service that requires approval before you get the authorization, the Plan will not pay for it. It is best to talk to your PCP before you get nonemergency services or supplies.
The prior authorization list includes many of the common services you might need, but it might not include every service and every detail about a service. It also can change as state regulations change, as services available from our providers change, and as medicine itself advances.
For more detailed information, see the Prior Authorization List or Your GA-U Benefits.
If you have questions, phone the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
Prior Authorization List
The drugs and services on this list must be reviewed for medical necessity and approved by Community Health Plan before you get the drug or service. Otherwise, Community Health Plan will not pay for them. If a service is not listed, it might not be a Community Health Plan covered benefit.
Important notes:
- This list gives you general information. Whether your service or treatment can be covered depends on your diagnosis. It is always best to check with your provider or Community Health Plan before you get the service.
- The information in this list is accurate at the time of it was posted. There might be changes to it during the calendar year.
More information:
- For more information about your benefits, see Your GA-U Benefits.
- For more information about what "medically necessary" means, see Medically Necessary.
- For details of which services are offered by Community Health Plan, contact your provider or phone the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.
Care That Requires a Prior Authorization Includes
Drugs/Injectables
(See important notes following the list.)
You need a prior authorization for:
- 17 Alpha-hydroxyprogesterone
- Abatacept (Orencia)
- Adalimumab (Humira)
- Amifostine (Ethyol)
- Bevacizumab (Avastin)
- Botulinum toxin (Botox/Myobloc)
- Certolizumab (Cimzia) NEW
- Cetuximab (Erbitux)
- Corticotropin (Acthar) NEW
- Docetaxel (Taxotere)
- Erythropoeisis-stimulating agents (Darbepoetin and Epoetin)
- Epoprostenol (Flolan)
- Etanercept (Enbrel)
- Gemcitabine (Gemzar)
- Golimumab (Simponi) NEW
- GnRH agonists (such as Lupron)
- Granulocyte-colony stimulating factor (G-CSF) (such as Pegfilgrastim)
- Growth hormone (Somatropin)
- Hyaluronic acid derivatives (such as Synvisc/Hyalgan)
- Iloprost (Ventavis)
- Infliximab (Remicade)
- Intravenous immunoglobulin NEW
- Natalizumab (Tysabri)
- Octreotide (Sandostatin)
- Omalizumab (Xolair)
- Oxaliplatin (Eloxatin)
- Palivizumab (such as Synagis)
- Pamidronate (Aredia) and Zolendronic Acid (Zometa)
- Rituximab (Rituxan)
- Trastuzumab (Herceptin)
- Treprostinil (Remodulin)
Important notes about drugs:
- If the drug can be self-administered, you need a prescription plus a Plan-approved prior authorization from the Community Health Plan pharmacy benefit manager.
- If you cannot self administer the drug, you need an approved prior authorization from Community Health Plan.
- To find out how to get a pharmacy prior authorization, see Nonformulary and Prior Authorization Requests.
Home Health and Home Infusion
Radiology
- CT angiography
- CT head (non-emergency)
- All MRI imaging
- PET scan
Surgical Procedures
Community Health Plan requires prior authorization for all inpatient, planned procedures and for those outpatient procedures included in the list below.
Specific services that require authorization include:
- Blepharoplasty
- Breast prostheses or implants
(Does not require prior authorization for treatment related to breast cancer.) - Breast reduction or mammoplasty
- Bunionectomy
- Capsule endoscopy
- Cataract removal or lens implant
- Cervical or lumbar spine fusion
- Cervical or lumbar laminectomy
- Endovenous laser or radiofrequency ablation
- Hip, knee, or shoulder replacement
- Hysterectomy
- Knee arthroscopy
- Rhinoplasty and septoplasty
- Sclerotherapy, leg veins
- Urethral suspensions (incontinence)
- Uvulopalatopharyngoplasty (UPPP)
- Cardiac rehabilitation
- Physical therapy, occupational therapy, or speech therapy for more than 12 visits per year
Other
- Hyperbaric oxygen treatment
