2025 Plan Benefits

For the benefit year of 2025 here is what you’ll get and what you will pay:

• Doctor Visit: $0
• Vision care: a combined limit of  $350 each year for contact lenses and/or eyeglasses (frames and lenses)
• Inpatient Hospital Care: $0
• Home Health Agency Care: $0
• Ambulance Services: $0
• Transportation: $0. Including bus pass. Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
• Diagnostic Tests, X-Rays & Lab Services: $0
• Durable Medical Equipment: $0
• Home and Community Based Services (HCBS): $0
• Community Based Adult Services (CBAS): $0
• Long Term Care that includes custodial care and facility: $0
• Over the Counter (OTC) items allowance of $40 per quarter (every 3 months) towards the purchase of certain Over the Counter (OTC) items.
  
• Utilities allowance of $65 for covered utilities. You must qualify for this benefit.*
• Healthy Meals benefit of 2 meals per day, 365 days per year. You must qualify for this benefit.*

With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.

• Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.

After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook

• 2025 Summary of Benefits
• 2025 Annual Notice of Changes
• 2025 IEHP DualChoice Member Handbook

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.

There is a monthly premium of $0-$29.70 for IEHP DualChoice. You may qualify for “Extra Help” which can help reduce your monthly premium.

There is no deductible for IEHP DualChoice.

Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help. 

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:

• 1-800-MEDICARE (1-800-633-4227). , TTY users should call 1-877-486-2048, 24 hours a day/7days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call 1-800-325-0778; or
• Your State Medicaid Office

Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.

To speak with a care coordinator, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8 a.m. -8 p.m. (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.

What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).

• Preventive services
• Routine women’s health care and family planning services. This includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
• Flu shots and COVID-19 vaccinations as well as hepatitis B vaccinations and pneumonia vaccinations as long as you get them from a network provider.
• Emergency services from network providers or from out-of-network providers.
• Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside our plan’s service area. If possible, please call IEHP DualChoice Member Services before you leave the service area, we can help you receiveddialysis while you’re away.
• Sexually transmitted infection (STI) diagnosis and treatment
• Sensitive confidential services
• HIV testing and counseling at the Local Health Department
• Biomarker testing for advanced or metastatic stage 3 or 4 cancers
• Additionally, if you are an American Indian Member, you may obtain covered services from an Indian health Care provider of your choice, without requiring a referral from the Network PCP or Prior Authorization

A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

• Oncologists care for patients with cancer.
• Cardiologists care for patients with heart conditions.
• Orthopedists care for patients with certain bone, joint, or muscle conditions.

You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use. 

Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.

When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.

* You must have both diabetes and cardiovascular disease and meet other criteria to qualify. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided.   Please see your Member Handbook for more information.  Medicare approved IEHP DualChoice to provide this benefit as part of the Value Based Insurance Design program. This program lets Medicare try new ways to improve Medicare Advantage plans.

* You must have at least one chronic condition such as (cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, diabetes mellitus, and neurologic disorders) and meet other criteria to qualify. There may be other eligible chronic conditions that are not listed. For information on additional eligible chronic conditions see your Member Handbook. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided.   Please see your Member Handbook for more information. Medicare approved IEHP DualChoice to provide this benefit as part of the Value Based Insurance Design program. This program lets Medicare try new ways to improve Medicare Advantage plans.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 


Information on this page is current as of October 15, 2024.
H8894_DSNP_4892019_M_2025