Benefits for 19-63 year olds

Studies show the more you are involved with your health, the happier you are with your care. Regular doctor visits, vaccinations, tests, and dental exams support good physical and mental health.

As a partner in your journey to better health, we are here to answer any questions about your health plan and help you get the care you need.

Here are a few things to consider:

Choose a doctor and dentist. Making sure you have a primary care provider (PCP) and dentist that you can maintain an ongoing relationship with is important for your overall health.
Schedule yearly checkups. These visits may include talking to your doctor about important topics such as annual exams and screenings, family planning, healthy aging, exercise and managing stress.
Have regular dental checkups. The health of your mouth impacts your overall health. This is why good oral health is important. Regular checkups may include a cleaning, sealants, fluoride and X-rays.
Get a referral from your PCP. You must have a referral from your PCP in order to see most specialists (e.g., dermatologist, cardiologist, ENT, oncologist)

What does your health plan cover?

See what medical and dental services your plan will cover.

Benefit type	In-network coverage	What you need to know

Medical
Primary care provider (PCP)	Covered	All EOCCO members have an in-network PCP or clinic assigned to them.
Yearly checkups	One visit per calendar year	It is important to schedule a checkup every year. Your doctor will provide a physical exam and discuss important topics such as healthy eating, exercise, getting caught up on shots, safe sex, and how to manage stress in a confidential setting. Other preventative screenings and topics may be discussed as well.
Immunizations (shots)	Covered	A referral is not needed. Your doctor or any network provider can provide these.
Emergency room	Covered	An emergency is a condition that puts your life in danger. Call 911 or go to the emergency room when you think you are in danger.
Urgent care	Covered	Care that you need the same day for serious pain, to keep an injury or illness from getting much worse, or to avoid losing function in part of your body. You do not need an appointment.
Specialist	Covered	You will need a referral from your doctor before seeing a specialist.
Hospital	Covered	Prior approval is needed for in-patient hospital stays. Your doctor will get this approval. The prior approval is not needed in an emergency.
Labs, tests, X-rays	Covered	These are covered if your doctor orders them. Other authorized specialists may also order them.

Reproductive health and family planning
Physical exam	Covered	Women's annual exam, and family planning visit.
STI testing	Covered	Testing for sexually transmitted infections will be covered if your doctor or other healthcare provider believes you may be at risk. You may also request these services from your provider.
Birth control supplies and education	Covered	Your doctor or other health care professional will discuss your different birth control options with you. Your plan covers your choice of birth control, including emergency contraception.
Pregnancy test	Covered	Pregnancy tests are covered when ordered by a healthcare provider. Tests and results are confidential.

Vision
Exam	Limited coverage	Members age 20 and younger can have an eye exam every 12 months. Pregnant woman 21 or older can have an eye exam every 24 months.
Glasses and contact lenses	Limited coverage	Members age 20 and younger can have new glasses or contacts lenses every 12 months. Pregnant woman 21 or older can have new glasses or contacts every 24 months.

Hearing
Hearing test	Covered	If you are needing hearing services, your doctor will make a referral.
Hearing aids	Covered	If you are needing hearing services, your doctor will make a referral.

Behavioral health
Outpatient Mental health assessments, group therapy and therapy	Covered	You can access help for any mental health services. No referral is needed.
Intensive care coordination	Covered	You can refer yourself for care coordination services, or someone can refer you. No referral or preapproval required.
Early Assessment & Support Alliance (EASA)	Covered	Provides information and support to young people experiencing symptoms of psychosis for the first time. Available for ages 15-25.
Substance use treatment	Covered	You can get substance use disorder (SUD) services without a referral. Inpatient SUD, residential and detox services need preapproval.
Crisis services	Covered	No limits to the number of visits. No referral or preapproval required.
Assertive Community Treatment (ACT)	Covered	Must be at least 18 years old and meet ACT criteria.
Specialty Services such as Neuropsych and Psychological Evaluations	Covered	These evaluations need to be prior authorized and meet medical necessity and / or medical appropriateness

Dental
Preventive care	Covered	Exams, cleanings, flouride, varnish, and X-rays.
Restorative care	Covered	Treatment for cavities and other problems including: fillings, tooth removal, crowns, and dentures. Root canals on back teeth for pregnant women and adults age 18-20.
Specialist care	Covered	A referral may be needed to see a specialist. Please speak to your dentist before scheduling a specialist appointment.
Orthodonia (braces)	Not covered	Braces are not covered unless to treat cleft palate
Urgent and immediate treatment	Covered	Dental conditions that do not require emergency room care. Examples include: toothache, swollen gums, lost filling
Emergency dental care	Covered	24 hours, 7 days a week. In a dental emergency, call your dentist day or night.

Pharmacy
Prescription medications	Covered	These are medications that a PCP, specialist or other provider prescribes. You can get your prescriptions at any in-network pharmacy. A list of these pharmacies is in the provider directory.
Get more pharmacy-related information

Screenings
Weight assessment and counseling in adolescents	Covered	Preventive care
Mammogram (breast X-ray)	Covered	Preventive care
Prostate screening	Covered	Preventive care
Colorectal screening	Covered	Preventive care
Drug and alcohol screening	Covered	Behavioral health
Depression screening and follow-up plan	Covered	Behavioral health

Coverage by age

View benefits and coverage for other age groups.

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