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Tiếng Việt CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1.888.421.8444 (California Relay Service (CRS) 711). 한국어 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1.888.421.8444 (
)번으로 전화해 주십시오.
繁體中文 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 。 Հ այ ե ր ե ն ՈՒՇ ԱԴՐ ՈՒԹՅ ՈՒՆ՝ Եթ ե խո ս ո ւ մ եք հ այ ե ր ե ն, ապա ձեզ ան վ ճ ար կ ար ո ղ ե ն տր ամ ադ ր վ ե լ լ ե զ վ ակ ան աջ ակ ց ո ւ թյ ան ծ առ այ ո ւ թյ ո ւ ն ն ե ր : Զան գ ահ ար ե ք Р ус с ки й ( ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните
日本語 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 まで、お電話にてご連絡ください。
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau
ภาษาไทย เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริ การช่วยเหลือทางภาษาได้ฟรี โทร
ພາສາລາວ ້ າພາສາ ລາວ, ການບ ໂປດຊາບ: ຖ ້ າວ ່ າທ ່ ານເວ ໍ ິ ລການຊ ່ ວຍເຫ ້ ານພາສາ, ໂດຍບ ໍ່ ເສ ່ າ, ຼື ອດ ັ ຽຄ ແມ ່ ນມ ້ ອມໃຫ ້ ທ ່ ານ. ໂທຣ ີ ພ
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at 1.888.421.8444
at 1.888.421.8444
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Appointment Scheduling Maximum Waiting Time Emergency Services Immediately Urgent Care appointments do not require prior Must offer the appointment within 48 authorization hours of request Non-urgent appointments for Primary Care Must offer the appointment within ten (10) Business Days of the request Non-urgent appointments with Specialist Must offer the appointment within 15 physicians Business Days of the request Non-urgent appointments for ancillary services Must offer the appointment within 15 (for diagnosis or treatment of injury, illness, or Business Days of the request other health condition) Waiting time in provider office (to see provider) is Appointment Scheduling Maximum maximum 30 minutes Waiting Time
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Telehealth services will be subject to the same deductible and annual or lifetime dollar maximum as equivalent in-person services.
Low vision exam Low vision aids
Comprehensive evaluation is Covered in Full Approved low vision aids are Covered in Full
Once every calendar year Once every calendar year
Pre-Authorization required Pre-Authorization required
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medically necessary services to treat Severe Mental Illnesses (“SMI”) and Serious Emotional Disturbances of a child (“SED”).
medically necessary for the treatment of severe mental illnesses (“SMI”) and serious emotional disturbances of a child (“SED”)
medically necessary for the treatment of severe mental illnesses (“SMI”) and serious emotional disturbances of a child (“SED”)
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race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, gender expression
or any other classification prohibited by state or federal laws.
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