Member Benefits

All services, benefits, care, and treatment authorized by your primary care physician (PCP) or primary care team (PCT) are provided completely free of charge by Commonwealth Care Alliance. You are covered in full for the services listed below provided they are coordinated by the PCP or PCT. You will have no out-of-pocket expense for services authorized by your PCP or PCT.

Services and Care You May Receive:

*For more detailed information on the services below, click here to see the Senior Care Options HMO Evidence of Coverage. [Important: Please also read the Evidence of Coverage errata and corrections (pdf)]

Emergent/urgent care
Outpatient Health Services
Inpatient Hospital Care
Skilled Nursing Facility, Inpatient Rehabilitative Care
Outpatient Surgery
Home Health Care
End-of-Life Support (Hospice Services)
Health-Related Services (including transportation, homemaker/chore services, Personal Care Attendant services, respite care, dementia and social day care, environmental accessibility adaptations, personal emergency response systems, and companion services)
Diagnostic Dental Care
Specialists, Specialty Care
Behavioral Health Services
Prescriptions and Pharmacy Benefits (the SCO program covers outpatient prescription medications. There is no out-of-pocket expense for prescriptions, although some prescription drugs may require authorization and some drugs may have a maximum quantity limit)
Preventative Care and Screenings (including bone mass measurements, colorectal screenings, mammography screenings, prostate cancer screening exams, cardiovascular screening blood tests, and diabetes self-monitoring training and supplies)
And any additional services recommended by your PCP or PCT

Urgent, Emergency, and Out-of-Area Care

Authorization by the PCP is not required for Commonwealth Care Alliance to pay for your emergency care. Commonwealth Care Alliance will also cover medically necessary post-stabilization care services following emergency services. If you are receiving care in a hospital that is not affiliated with your PCP or are not a facility contracted by Commonwealth Care Alliance, the PCP may arrange a transfer to one of our contracted hospital when your condition is stable and it is medically appropriate to do so.

Authorization by the PCP is not required for Commonwealth Care Alliance to pay for your urgently needed care. Out-of-area urgent care coverage is available when you may need medical attention right away for an unforeseen illness or injury and it is not reasonable for you to get the care you need from the PCP or plan providers. If you are out of our service area for a short time and cannot wait until you return home to get the care you need, Commonwealth Care Alliance will pay for the urgently needed care.

Last Updated 1/6/10