Benefits Guide

Benefits and Services

Your doctor must arrange and approve all your care before you receive services. Exception: Emergency room and out of area urgent care services do not require prior authorization.

Call our Member Services Department at 1-888-839-9909 if you have any questions.

 

Summary of Benefits

Services described in the Summary of Benefits table are brief descriptions. For full explanation of your benefits, please see the Plan Benefits pages in your Member Handbook.

Click here to access the PASC-SEIU Plan Member Handbook. (PDF)

Benefits Covered Services Member Pays
Asthma Care

Coverage for medically necessary supplies and equipment relating to the management and treatment of asthma, including inhaler spacers, nebulizers (including face masks and tubing), peak flow meters and education on the proper use of these items.

Members identified with asthma are enrolled in the L.A. Cares About Asthma® disease management program that includes educational mailings and phone condition monitoring by a nurse for high-severity members. For inquiries on the program or to opt out of the program, members can contact: 1-888-200-3094 (TTY/TDD) 711 Monday through Friday 8 a.m. to 4 p.m. or email:
asthmadm@lacare.org

No co-payment
Blood and Blood Products Inpatient and outpatient processing, storage, and administration and collection, and storage of autologous blood, when medically necessary. No co-payment
Cancer Clinical Trials Coverage for a member's participation in a cancer clinical trial, phase I through IV, when the member's physician has recommended participation in the trial and member meets certain requirements $5 per visit

Co-payment for prescriptions as described in the "Prescription Drug Program"
Cataract Spectacles and Lenses Cataract spectacles and lenses, cataract contact lenses or intraocular lenses that replace the natural lens of the eye after cataract surgery No co-payment
Confidential HIV and STD Testing Testing available from L.A. County Department of Health Services, family planning services providers, your doctor, or prenatal clinics; no prior authorization required No co-payment
Dental Services Only when medically necessary; no coverage for routine dental services (e.g., cleaning, cosmetic)

Routine dental coverage is offered separately and paid through a monthly payroll deductions to SEIU. For information, contact SEIU at 1-877-698-5829.
No co-payment
Diabetic Care

Equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary, even if the items are available without prescription. Training and health education for diabetes self-management. Family education for self-management.

Members identified with diabetes are enrolled in the L.A. Cares About Diabetes® disease management program that includes educational mailings and phone condition monitoring by a nurse for high-severity members. For inquiries on the program or to opt out of the program, members can contact: 1-877-796-5878 (TTY/TDD) 711 Monday through Friday, 8 a.m. to 4 p.m. or email diabetesdm@lacare.org

No co-payment
Diagnostic, X-Ray and Laboratory Services Therapeutic radiological services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests No co-payment
Durable Medical Equipment Equipment for home used as medically necessary No co-payment
Emergency Care Services Health care services which a reasonable person would consider necessary to relieve a serious illness or symptom, injury, severe pain, or condition requiring immediate diagnosis. Offered 24 hours a day, seven days a week. $35 per visit (waived if admitted to hospital)
Emergency Contraception FDA-approved contraceptive drugs and devices No co-payment
Eye Exam/Vision Services No coverage for routine vision services (eyeglasses and contact lenses)  
Family Planning Services Voluntary family planning services No co-payment
Health Education Services Effective health education services and materials. This includes education on personal health behavior and health care, and recommendations regarding the optimal use of health care. No co-payment
Home Health Care Services Services provided at the home by health care personnel
Medically necessary skilled care; does not cover custodial care
No co-payment
Hospice Medically necessary skilled care; counseling; medical supplies; short term inpatient care; pain control and symptom management; bereavement services; physical, speech and occupational therapies; medical social services; and respite care No co-payment
Hospital Services — Inpatient Room and board, nursing care and all medically necessary ancillary services
  • dialysis
  • anesthesia
  • obstetrical care and delivery (including Caesarean section)
No co-payment
Hospital Services — Outpatient Diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility No co-payment
  • Ambulatory surgery
No co-payment
  • Specialty care consultations/visits
No co-payment
  • Therapeutic radiology, chemotherapy, renal dialysis
No co-payment
  • Physical, occupational and speech therapy performed on an outpatient basis
$5 per visit
  • Emergency health care services.
    (waived if the member is hospitalized)
$35 per visit
Human Papillomavirus Screening & Vaccine (HPV) Screening test for cervical cancer available to all female members ages 9 through 26 No co-payment
Medical Nutrition Therapy Treatment of diagnosed medical conditions (uncontrolled diabetes, obesity, underweight or pre-end-stage renal disease) through dietary interventions. Requires physician order. No co-payment
Medical Transportation Ambulance transportation in an emergency No co-payment
Mental Health — Inpatient Care

Prior authorization is required for the following inpatient, in-network services:

  • Adult Residential Treatment Services
  • Psychiatric Inpatient Hospital Services
  • 23-hour Observation
  • Crisis Residential Treatment Services


Call L.A. Care's toll-free behavioral health hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

No co-payment
Mental Health — Outpatient Visits

Services obtained during a provider office visit, outpatient hospital visit, or urgent care visit.
This includes:

  • Individual and Group Therapy
  • Medication Management
  • Diagnostic Evaluation
  • Crisis Intervention

Prior authorization is required for psychological testing.
Call L.A. Care’s toll free behavioral health hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

$5 per visit
Mental Health - Outpatient Facility-Based Services

Services outside of an office setting, such as a treatment center or home, that involve daily or weekly treatment delivered over several hours. Prior authorization is required for the foll wing outpatient, in-network services:

  • Acute Partial Hospitalization
  • Intensive Outpatient
  • Behavioral Health Treatment for Autism Spectrum Disorders (includes Asperger’s Syndrome, Autism and Pervasive Developmental Disorder)
  • Transcranial Magnetic Stimulation (TMS)
  • Outpatient Electroconvulsive Therapy (ECT)
  • Intensive Day Treatment

Call L.A. Care’s toll free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

No co-payment
Physical, Occupational and Speech Therapy Outpatient $5 per visit
Inpatient

Therapy may be provided in a medical office or other appropriate outpatient setting
No co-payment
Pregnancy and Maternity Care Prenatal and postpartum care No co-payment
Prescription Drug Program

Drugs prescribed by a licensed practitioner

  • 30-day supply for generic drugs. See limitations for brand name drugs under "Plan Benefits"
$5 per prescription
  • 90-day supply of maintenance drugs — generic only
$5 per prescription
  • Prescription drugs provided in an inpatient setting
No co-payment
  • Drugs administered in the doctor's office or in an outpatient facility
No co-payment
  • FDA-approved contraceptive drugs and devices
No co-payment
  • Respiratory devices for the management and treatment of asthma

    Call Member Services for mail order form or for a list of participating pharmacies at 1-888-839-9909.
No co-payment
Preventive Care Services
  • Periodic health exams
$5 per visit
  • Immunizations, STD tests, and cytology exams on a reasonable periodic basis
No co-payment
  • Vision/Hearing Screening
No co-payment
  • Cancer Screening
No co-payment
  • Health Education
No co-payment
  • Well-Child Care — limited to first 31 days of life
No co-payment
Professional Services
  • Outpatient Visit Urgent care; office visit, or home visit
$5 per visit
  • Specialty care consultations/visits
$2 per visit
  • Chemotherapy, dialysis, surgery, anesthesiology, or radiation
No co-payment
  • Inpatient Visit Licensed hospital, skilled nursing facility, hospice, mental health facility
No co-payment
Prosthetics and Orthotics Prosthetics and orthotics as prescribed by L.A. Care providers No co-payment
Reconstructive Surgery Reconstructive surgery repairs abnormal body parts, improves body function, or brings back a normal look. No co-payment
Skilled Nursing Care Services provided in a licensed skilled nursing facility. Benefit is limited to a maximum of 100 days per benefit year. No co-payment
Substance Use Disorder Treatment Outpatient–Facility-Based Services

Prior authorization is required for the following in-network services:

  • Acute Partial Hospitalization
  • Intensive Outpatient

Call L.A. Care’s toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

No co-payment
Substance Use Disorder Treatment – Inpatient Care

Prior authorization is required for the following inpatient, in-network services:

  • Inpatient Acute Detoxification
  • Inpatient Rehabilitation
  • Residential Detoxification
  • 23-Hour Observation

Call L.A. Care’s toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

No co-payment
Substance Use Disorder Treatment – Outpatient Visits

Services obtained during a provider office visit, outpatient hospital visit, or urgent care visit.
This includes:

  • Opioid Replacement Therapy
  • Diagnostic Evaluation
  • Crisis Intervention
  • Individual and Group Therapy

Call L.A. Care’s toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you.

$5 per visit
Transplants Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ No co-payment


The PASC-SEIU health benefit plan in Los Angeles County is considered a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your PASC-SEIU health benefit plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
 

Call our Member Services Department at 1-888-839-9909 if you have any questions.