Your Benefits

What We Cover

We cover everything that MassHealth Standard and Medicare plans cover. And on top of that, you pay nothing for these covered services as long as you follow our rules for getting care.

Services you can get at no cost to you

  • Doctor’s visits
  • Prescription and over-the-counter drugs
  • Mental health services
  • Dental exams, cleanings, dentures, root canals
  • Vision care
  • Skilled nursing facilities
  • Hearing services
  • Home health care
  • Inpatient hospital care
  • Durable medical equipment such as wheelchairs, walkers, oxygen tanks
  • Short-term respite care
  • Rides to appointments

A complete list of covered services is located in your Summary of Benefits.

Some Services Require Approval Before You Can Get Them

You may need approval before getting certain care. Some services such as procedures, medications, or visits to doctors outside our network require approval from us before you can get them. This is sometimes called “prior authorization”. Covered services that need advanced approval are marked in your Summary of Benefits document in bold.

Need a service that is not listed?

You may find that a service you would like to get is not listed as a covered benefit. The good news is that you can ask us to cover medical services or drugs that you think you need.

You can request coverage for medical care you want

You, your doctor, or your authorized representative can ask us to cover a service that we don't typically cover. We will review your situation and decide if we will pay for the medical service you want. This is called an organization determination.

To submit this request, either call, write, or fax our Member Services department.

Usually we provide our decision within 14 calendar days of receiving your request. Sometimes it can take more if we need more information (such as medical records that are hard to track down). If your health requires it, we can make the decision faster (within 72 hours).

You can request coverage for a prescription drug that you want

You can also request that we cover a drug that we do not typically cover, or that we remove restrictions from a drug. Your provider or authorized representative can help you request this exception and provide reasons why he/she thinks you need the drug. This is also called a coverage determination. We will review your situation and decide if we will pay for the drug.

Learn how to request coverage for a drug.

If you disagree with our decision you can make an appeal

This means that you can ask us to reconsider our decision. Learn more about appeals.

Limitations and restrictions may apply. Benefits, formulary, pharmacy network and provider network may change on January 1 of each year. You will receive notice when necessary.

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