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Benefits

We Are Proud to Offer Many Covered Services.

But first, here are a couple of important things to remember when getting your care: 

  • WellCare or a network doctor must approve your care 
  • If you get a service that we do not approve, you may have to pay for it yourself 
  • Sometimes we may not have a provider in our network who can give you needed care; if this happens, we’ll cover the care out-of-network (at no additional cost to you), but you will need to get approval first from us or your PCP 

If you are not sure whether the plan pays for a service call customer service at 1-866-231-1821 (TTY 1-877-247-6272).

Services We Do Not Cover

We do not offer these services:

  • Chore services
  • Long-term nursing home stays over 30 days
  • Meals-on-Wheels
  • Portable X-rays
  • Routine foot care
  • Services for flatfoot
  • Social services
  • Subluxation
  • Vitamin B-12 injections

Covered Services and Co-Payments

PeachCare for Kids® monthly premiums are low-cost or free. Payments are based on your child's age and your family income.


Health Services & Co-Pay Information

Emergency Services

Family planning-related only (i.e., a complication after a tubal ligation procedure)

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
$0 (if an emergency)
$3 (if not an emergency)

Inpatient Hospital Services

Psychiatric hospitalizations up to 30 days are covered

(per treatment episode)

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
$12.50 (unless admitted from an emergency room 
or transferred from another health facility)

Outpatient Hospital Services (non-emergency)


Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
$3 (non-emergency 
hospital visit)

Ambulatory and Related Services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
$3
$3

Prescription Drugs

See our Preferred Drug List (PDL) for the drugs we cover

This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits or gender limits

Drugs not on our PDL may be covered with a prior authorization

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

Preferred Drugs—$.50

Non-preferred drugs—co-pays are based 
on the cost of the drug as follows:
Cost of Drug
$10.00 or less
$10.01–$25.00
$25.01–$50.00
More than $50.01
Co-Pay
$.50
$1
$2
$3
Pregnant women, nursing facility 
residents and hospice care members do 
not have co-pays

Behavioral Health Services

Limits

Younger than age 21—up to 30 days are covered

Services in a state-operated mental hospital or institution for mental diseases are not covered

Age 21 and older—as medically necessary

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Dental Services for Medicaid members under age 21 and PeachCare for Kids® members (Health Check)

Services include:

  • 2 exams each benefit year
  • 2 cleanings each benefit year
  • 2 fluoride treatments each benefit year
  • 1 filling per tooth
  • Dentures—1 pair every 3 years
  • Denture repairs—2 adjustments each benefit year
  • Oral surgery
  • Orthodontic treatment—when medically necessary and prior authorized

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Dental Services for members over age 21

Services include:

  • Emergency and related dental services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Dental Services for members over age 21

Services include:

  • 2 exams
  • 2 fluoride treatments
  • 1 filling per tooth
  • Periodontal treatments—when medically necessary and prior authorized

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Hearing Services for Medicaid members under age 21 and PeachCare for Kids® members (Health Check)

Services include:

  • Tests
  • Hearing aids—1 every 3 years
  • Hearing aid fitting and dispensing
  • Hearing aid repairs and parts
  • Inner ear implants
  • Newborn hearing tests—based on medical necessity

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0


Physician Services—PCP and Specialist Visits

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
$0
$2

Vision Services

For Medicaid members under age 21 and PeachCare for Kids® members (Health Check), services include:

  • 1 eye exam each year
  • 1 par of glasses per year
  • 1 pair of lenses per year

For adults age 21 and older with chronic diseases (like diabetes):

  • Vision exam
  • Emergency care

Medicaid Co-Pays
PeachCare for Kids®
(age 6 and up) 
Co-Pays
$0 Cost of Service
$10.00 or less
$10.01–$25.00
$25.01–$50.00
More than $50.01
Co-Pay
$.50
$1
$2
$3

Emergency Transportation Services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Family Planning Services and Supplies

Contraceptive supplies and follow-up care

Contraceptive management, education and counseling

Diagnosis and treatment of sexually transmitted infections (except for HIV/AIDS and hepatitis)

Drugs, supplies or devises related to women's health services that are prescribed by a physician or advanced practice nurse

Drugs for treatment of lower genital tract and genital skin infections/disorders and urinary tract infections, when the infection/disorder is identified or diagnosed during a routine/periodic family planning visit. A follow-up visit for the treatment/drugs may be covered.

Initial and annual complete physical exam, including a pelvic exam and Pap test, as well as follow-up visits (up to four)

Pregnancy testing

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays
 $0

Federally Qualified Health Center Services


Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$2

Rural Health Clinic Services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$2

Targeted Case Management

Covered for:

  • Pregnant women under age 21 and other pregnant women at risk for adverse outcomes
  • Infants and toddlers with established risk for developmental delay
Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Nurse Practitioner Services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Nursing Facility Services

Long-term nursing facility stays (more than 30 days) are not covered

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Private-Duty Nursing Services

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Occupational Therapy Services

Younger than age 21—as medically necessary

Age 21 and older—as medically necessary for short-term rehabilitation

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

Physical Therapy Services

Younger than age 21—as medically necessary

Age 21 and older—as medically necessary for short-term rehabilitation

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$2

Speech Therapy Services

Younger than age 21—as medically necessary

Older than age 21—as medically necessary for short-term rehabilitation

Medicaid Co-Pays
PeachCare for Kids® 
(age 6 and up) 
Co-Pays

$0

  • Hospital and Emergency Services

    Emergency Services

    Family planning-related only (i.e., a complication after a tubal ligation procedure)

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
    $0 (if an emergency)
    $3 (if not an emergency)

    Inpatient Hospital Services

    Psychiatric hospitalizations up to 30 days are covered

    (per treatment episode)

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
    $12.50 (unless admitted from an emergency room 
    or transferred from another health facility)

    Outpatient Hospital Services (non-emergency)


    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
    $3 (non-emergency 
    hospital visit)
  • Ambulatory or Related Services

    Ambulatory and Related Services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
    $3
    $3
  • Prescription Drugs

    Prescription Drugs

    See our Preferred Drug List (PDL) for the drugs we cover

    This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits or gender limits

    Drugs not on our PDL may be covered with a prior authorization

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    Preferred Drugs—$.50

    Non-preferred drugs—co-pays are based 
    on the cost of the drug as follows:
    Cost of Drug
    $10.00 or less
    $10.01–$25.00
    $25.01–$50.00
    More than $50.01
    Co-Pay
    $.50
    $1
    $2
    $3
    Pregnant women, nursing facility 
    residents and hospice care members do 
    not have co-pays

  • Behavioral Health Services

    Behavioral Health Services

    Limits

    Younger than age 21—up to 30 days are covered

    Services in a state-operated mental hospital or institution for mental diseases are not covered

    Age 21 and older—as medically necessary

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

  • Physician, Dental, Vision and Hearing Services

    Dental Services for Medicaid members under age 21 and PeachCare for Kids® members (Health Check)

    Services include:

    • 2 exams each benefit year
    • 2 cleanings each benefit year
    • 2 fluoride treatments each benefit year
    • 1 filling per tooth
    • Dentures—1 pair every 3 years
    • Denture repairs—2 adjustments each benefit year
    • Oral surgery
    • Orthodontic treatment—when medically necessary and prior authorized

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Dental Services for members over age 21

    Services include:

    • Emergency and related dental services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Dental Services for members over age 21

    Services include:

    • 2 exams
    • 2 fluoride treatments
    • 1 filling per tooth
    • Periodontal treatments—when medically necessary and prior authorized

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Hearing Services for Medicaid members under age 21 and PeachCare for Kids® members (Health Check)

    Services include:

    • Tests
    • Hearing aids—1 every 3 years
    • Hearing aid fitting and dispensing
    • Hearing aid repairs and parts
    • Inner ear implants
    • Newborn hearing tests—based on medical necessity

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0


    Physician Services—PCP and Specialist Visits

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
    $0
    $2

    Vision Services

    For Medicaid members under age 21 and PeachCare for Kids® members (Health Check), services include:

    • 1 eye exam each year
    • 1 par of glasses per year
    • 1 pair of lenses per year

    For adults age 21 and older with chronic diseases (like diabetes):

    • Vision exam
    • Emergency care

    Medicaid Co-Pays
    PeachCare for Kids®
    (age 6 and up) 
    Co-Pays
    $0 Cost of Service
    $10.00 or less
    $10.01–$25.00
    $25.01–$50.00
    More than $50.01
    Co-Pay
    $.50
    $1
    $2
    $3

  • Transportation Services

    Emergency Transportation Services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

  • Family Planning Services and Supplies

    Family Planning Services and Supplies

    Contraceptive supplies and follow-up care

    Contraceptive management, education and counseling

    Diagnosis and treatment of sexually transmitted infections (except for HIV/AIDS and hepatitis)

    Drugs, supplies or devises related to women's health services that are prescribed by a physician or advanced practice nurse

    Drugs for treatment of lower genital tract and genital skin infections/disorders and urinary tract infections, when the infection/disorder is identified or diagnosed during a routine/periodic family planning visit. A follow-up visit for the treatment/drugs may be covered.

    Initial and annual complete physical exam, including a pelvic exam and Pap test, as well as follow-up visits (up to four)

    Pregnancy testing

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays
     $0
  • Health Center, Clinic and Case Management Services

    Federally Qualified Health Center Services


    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $2

    Rural Health Clinic Services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $2

    Targeted Case Management

    Covered for:

    • Pregnant women under age 21 and other pregnant women at risk for adverse outcomes
    • Infants and toddlers with established risk for developmental delay
    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

  • Health Center and Clinic Services

    Nurse Practitioner Services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Nursing Facility Services

    Long-term nursing facility stays (more than 30 days) are not covered

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Private-Duty Nursing Services

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

  • Therapy Services

    Occupational Therapy Services

    Younger than age 21—as medically necessary

    Age 21 and older—as medically necessary for short-term rehabilitation

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

    Physical Therapy Services

    Younger than age 21—as medically necessary

    Age 21 and older—as medically necessary for short-term rehabilitation

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $2

    Speech Therapy Services

    Younger than age 21—as medically necessary

    Older than age 21—as medically necessary for short-term rehabilitation

    Medicaid Co-Pays
    PeachCare for Kids® 
    (age 6 and up) 
    Co-Pays

    $0

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Last Updated On: 3/16/2017