...year even if you feel healthy. Breast Cancer Screening: Women between the ages of 50 to 75 should get a mammogram, an x-ray of your breasts, at least once every...

...months Comprehensive oral evaluations Limit: one every three calendar years Prophylaxis routine dental cleanings Routine Dental Cleanings Limit: one every six months Radiographs (x-rays) Routine periodic bitewing x-rays Limit: one...

...Transportation Yes $10 copay for ambulance transportation Dental Benefits Type of Service Package A Package C Prior Authorization Needed? Oral Exams and X-Rays Yes Yes Oral exams, x-rays and preventive...

...Urgent Care Usually, open 7 days a week with additional evening and weekend hours. When your provider is not available. Common illnesses, x-rays, deep cuts, etc. Used to treat a...

...health partners who offer these services. Services that Require a Referral Other services like lab tests, x-rays or physical therapy need a referral. That means you must get an OK...

...and X-Rays Yes No HIP Basic members age 19- 20 are eligible for (EPSDT) services and some limited enhanced preventive and diagnostic dental services. Yes Yes Yes Oral exams, x-rays...

These pharmacy policies apply to the TRICARE Prime® Demo by CareSource Military & Veterans™ plan. These pharmacy policies apply to our Georgia Medicaid plan(s). Pharmacy policies offer guidance on determination...

CareSource PASSE™ may update this page with information about how to work with our plan. Have a question not addressed on this page? Contact Provider Services at 1-833-230-2100. You can...

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here. 2018 Archived Pharmacy Policies 2019 Archived Pharmacy Policies 11/13/2019 Update...

...visits Home health care Preventive care and exams X-rays Asthma and diabetes programs Physical therapy Chiropractic services Lead screening tests for children Immunizations Family planning services Pregnancy and OB/GYN visits...