Medical Benefits

Your First ChoiceSM by Select Health benefits, benefits limits, and what to do:

  • Acute inpatient psychiatric services are free-standing psychiatric facilities that provide mental and behavioral health services. The current inpatient admission copay of $25 would apply for members over the age of 18 who are not part of a federally recognized Indian tribe and/or pregnant. (Effective July 1, 2019.) Have your First Choice network provider call First Choice for prior authorization.

  • Adult well visits are routine medical checkups to help make sure you are in good health. Make an appointment with your PCP.

  • Ambulance transportation is covered when medically necessary for your condition, and use of another method of transportation is not appropriate. Call 911 if there is an emergency.

  • Audiological services include testing, screening, preventive and/or corrective services for hearing disorders or determining if you have a hearing disorder. Services are free for members younger than age 21. Newborn hearing screenings are also covered by First Choice. Get a referral from your PCP or other Licensed Health Care Professional of the Healing Arts (LPHA)  

  • Autism Spectrum Disorder (ASD) services give mental health treatment to people with ASD. The member must be shown to have ASD before getting services. A complete psychological review must show a diagnosis. Services are available to members younger than age 21. Get a referral from your PCP or have your provider call First Choice for prior authorization.

  • BabyNet services are for children from birth up to 3 years who have developmental delays or conditions associated with developmental delays. They are provided in an outpatient setting. (Effective October 1, 2019.)Contact your First Choice provider for more details, including eligibility requirements.

  • Chiropractic care services are limited to 6 visits each year. Have your First Choice network provider call First Choice for prior authorization.

  • Communicable disease services help control and prevent diseases such as tuberculosis, sexually transmitted infections (STIs), and HIV/AIDS. Services include exams, assessments, diagnostic procedures, health education/counseling, treatment and contact tracing. Get care from any public health agency or make an appointment with your PCP.

  • Durable medical equipment includes medical products, surgical supplies and equipment when ordered by a physician as medically necessary. Call your PCP.

  • Family planning services include family planning exams, counseling services to help prevent or plan timing of pregnancy, birth control, family planning-related lab services and surgeries to prevent pregnancy. You do not need a referral or copay, or prior approval, but some services may need your doctor to fill out and send forms to First Choice. Members are encouraged to use First Choice network providers, but you may see any provider who accepts Healthy Connections. You are free to choose the method of family planning you use without coercion or mental pressure.

  • Gastric bypass surgery is a surgery that helps you lose weight. The surgery changes how your stomach and small intestine handle the food you eat. To make sure First Choice members get the best results, we will only approve weight loss surgery at hospitals with Preferred Bariatric Surgery Center status. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) must approve these hospitals. Approved hospitals are listed on the American College of Surgeons website at www.facs.org. If you are thinking about having weight loss surgery, check the website to make sure the hospital you are using is approved. Have your First Choice network provider call First Choice for prior authorization.

  • Home health care are services at your home, including intermittent skilled nursing, home health aide, physical, occupational and speech therapy. Adult members age 21 years and older are limited to 50 visits per year. This does not include nursing homes and institutions. Get a referral from your PCP.

  • Hysterectomies, sterilizations and abortions are covered under certain circumstances. Hysterectomies are covered when they are non-elective and medically necessary. Hysterectomies are not covered if performed solely for rendering the member incapable of reproducing. Sterilizations are limited to members at least 21 years old, mentally competent and have voluntarily given consent. Abortions are covered if the pregnancy is a result of rape or incest, or if the member suffers from a physical disorder, injury or illness (including a life-endangering condition caused by or from the pregnancy) and this places the member in danger of death unless an abortion was performed. Call your PCP or First Choice for more details.

  • Immunizations are covered for adult members 19 years of age and older. Covered services include the vaccine and administration of the vaccine. Adult vaccinations include serogroup B meningococcal (MenB); measles, mumps, and rubella (MMR); varicella (VAR); and measles, mumps, rubella, and varicella (MMRV). Coverage for members under 19 years of age is provided through the Vaccine for Children (VFC) program. Call your PCP.

  • Inpatient services are items and medical and behavioral services provided under the direction of a doctor if you are admitted to a hospital when the stay is expected to last more than 24 hours. This includes room and board, miscellaneous hospital services, medical supplies and equipment. Get a referral from your PCP.

  • Lab and X-rays are services ordered by a doctor and provided by independent labs and X-ray facilities. Call your PCP.

  • Life-threatening emergencies are identified when medical care is needed right away because of a danger to your life, limb(s) or sight if not treated right away. Call 911 or go to the nearest emergency room.

  • Long-term care covers the first 90 calendar days of continuous confinement in a long-term care facility or nursing home. First Choice may cover additional days until your disenrollment or a maximum of 120 calendar days. After this time, payment for services are made by the Medicaid fee-for-service program. Includes skilled nursing care or rehabilitative services. Get a referral from your PCP.

  • Maternity services include prenatal (pre-birth), delivery, postpartum (after birth) services and nursery charges for a normal pregnancy or complications related to the pregnancy. Females between the ages of 12 and 55 years of age are eligible for CenteringPregnancy® group prenatal care. CenteringPregnancy prenatal care is provided in a group setting, giving members more time with their provider up to 10 group visits before delivery. Call First Choice for a list of providers and more details.

  • Medicines and pharmacies (prescriptions and over-the-counter). There is a maximum 31-day supply. Some medicines need prior approval. Members may get an emergency supply of medicine that will cover them for 72 hours while a prior authorization request is pending. A member is permitted one temporary supply per prescription number. Inhalers, diabetic test strip and supplies, and creams or lotions are exceptions to the supply limit because of how they are packaged. For those medicines, the member may receive the smallest package size available. Generic medicine and supplies will be provided when available. Members may get a supply of certain medicines, that lasts 90 calendar days, to treat asthma, hypertension, diabetes, and high cholesterol. Call Member Services for complete information about covered medicines, the appeal process or a complete list of participating pharmacies. Get a prescription (including over-the-counter). Take it to a First Choice participating pharmacy. Present your First Choice and Healthy Connections ID cards. Call Member Services for a complete list of participating pharmacies.

  • Mental health, emotional health, and drug and alcohol services including those received through the Department of Alcohol and Other Drug Abuse Services (DAODAS) may need prior authorization. Your provider must call First Choice for prior authorization, when required, before rendering services. Get a referral from your PCP or have your provider call First Choice for prior authorization.

  • Obesity-management treatment is available for eligible adults over 21 years of age. Services include an initial screening, five additional face-to-face behavioral counseling visits, an initial dietitian visit for nutritional counseling and five follow up visits. Treatment for members up to age 21 is covered under the Well Child or Early Periodic Screening and Testing (EPSDT) benefit. Contact your PCP or First Choice for more detail including eligibility requirements.

  • Occupational, speech and physical therapy may require authorization in any setting. Your provider must call First Choice to see if authorization is needed. Private rehabilitative therapy is covered and limited to 105 combined hours of service per fiscal year (July 1 to June 30th). Therapy provided in a hospital-affiliated outpatient setting is covered for all members if medical necessity and required criteria are met, authorization is obtained when necessary, and is limited to 105 combined hours per fiscal year. Get a referral from your PCP.

  • Opioid treatment programs (OTPs) are for members with opioid use disorder who need medication-assisted treatment. Services include an assessment, counseling, and medications. They are provided in an outpatient setting. Medical necessity must be confirmed at the time of admission by either a physician or an advanced practice registered nurse (APRN) who is employed or contracted by the OTP. Members should use providers who are in the First Choice network. (Effective July 1, 2019.) For more information, or if you need help finding a First Choice network OTP, please call Member Services at 1-888-276-2020.

  • Outpatient Pediatric AIDS Clinic services (OPAC) include specialty care, consultation and counseling services for HIV-infected Medicaid-eligible children and their families. Outpatient Pediatric AIDS Clinic services or a First Choice network provider may provide care. Call your PCP or First Choice for more details.

  • Outpatient services are preventive diagnostic, therapeutic, rehabilitative, surgical and emergency services received for the treatment of a disease or injury at an outpatient/ambulatory care facility for a period of time under 24 hours. Get a referral from your PCP.

  • Podiatry is covered for medically necessary services for the testing and treatment of foot conditions. Get a referral from your PCP.

  • Primary care visits include visits to the personal doctor you chose from the First Choice Health Care Professional and Provider Directory. Make an appointment with your PCP.

  • Psychiatric assessment services are limited to a maximum of 1 assessment per member every 6 months. Contact your PCP or any provider who accepts Healthy Connections.

  • Psychiatric Residential Treatment Facility (PRTF) services are for people who need mental health care. They are provided in an inpatient facility. They are not provided in a hospital. Services include 24-hour supervision and specialized interventions. PRTF services are only for members under age 21. If a member is in the PRTF when he or she turns 21, services may continue until the member no longer needs them or when the member reaches age 22, whichever comes first. Have your First Choice Network Provider call First Choice for prior authorization.

  • Rehabilitative behavioral health services are provided to reduce the effects of mental disabilities and improve the ability to function. For more information or if you need help from a First Choice Care Manager, please call Member Services at 1-888-276-2020If prior authorization is needed, your First Choice Network Provider will handle the process for you.

  • Specialist visits are visits to a doctor who practices a certain area of medicine. You don't need a referral from your PCP. Make an appointment with the specialist.

  • Transplant services must have approval before being performed. Depending on the service and type of transplant, coverage may be provided by First Choice or Healthy Connections (the state Medicaid program). First Choice benefits cover all services for corneal transplants. However, First Choice only covers the services before and after other types of transplants (for example, a kidney transplant). Get a referral from your PCP or call your First Choice care manager.

  • Vision care

    Children under 21: Routine vision care is covered and includes the following once per year: one comprehensive eye exam, one pair of eyeglass lenses including frames, and one eyeglass fitting. It also covers one pair of replacement eyeglasses each year with no copay if the first pair is lost or damaged. For replacement eyeglasses, contact the eye doctor who provided the original pair. Vision care for children under age 21 does not need prior authorization when using a First Choice provider.

    Adult members age 21 and older: The adult vision benefit includes the following once every two years: one comprehensive eye exam with no copay, one pair of eyeglass lenses including frames, and one eyeglass fitting. Eye exams provided by a participating network provider will not require prior authorization. Prior authorization is needed to see providers NOT in the First Choice network. All eyeglass lenses, including frames, must be ordered from Robertson’s Optical from their Select Health Frame Kit; no prior authorization required. 

    Call Member Services for a list of First Choice providers, additional information, or questions about covered benefits and/or prior authorization requirements.

  • Well-child visits are routine medical checkups from birth through the month of the 21st birthday. Visits may include immunizations (shots). See page 21 of your Member Handbook (PDF) for recommended schedule of visits. Make an appointment with your PCP. 

  • Well-woman visits are routine medical checkups for women. They include a pelvic exam, breast exam, yearly sexually transmitted infections (STI) screening and, as recommended, a Pap test. It is also a chance to talk with your doctor about your health and reproductive health care needs. Make an appointment with your PCP or a First Choice OB/GYN.

Please contact Member Services at 1-888-276-2020 for a complete list of services provided by either First Choice or Healthy Connections. Services not covered by First Choice or Healthy Connections are non-covered services. For additional information about non-covered services, please call Member Services.