2023 DualConnect benefits & copays

Santa Clara Family Health Plan DualConnect (HMO D-SNP) (DualConnect), a Medicare Medi-Cal Plan, coordinates all of your Medicare and Medi-Cal benefits under one health plan, including:

Preventive, wellness, and chronic disease management services
Emergency and urgent care
Prescription medications, including Part D prescription coverage
Behavioral health services
Long-term services and supports (LTSS)
Community Supports

You can find a description of the 2023 benefits and copays in the sections below.

For more information, call SCFHP DualConnect Customer Service or read the SCFHP DualConnect materials below.

Annual Notice of Changes (ANOC)

Member Handbook (EOC)

Summary of Benefits

Provider and Pharmacy Directory - Updated 5/31/23

List of Covered Drugs (Formulary) - Updated 5/31/23

List of Durable Medical Equipment (DME)

Prior Authorization Requirements(Updated 5/31/23)
Step Therapy Requirements (Updated 5/31/23)
Language Assistance Services
Nondiscrimination Notice

Benefits and services

Benefits and Services

SCFHP DualConnect covers all services covered by Medicare and Medi-Cal. Benefits include:

Acupuncture
Behavioral health services (mental health and substance abuse treatment)
Chiropractic services
Dental care (You must get covered dental services through the Medi-Cal Dental Program. These services are a limited benefit. Contact Medi-Cal Dental toll-free at 1-800-322-6384 (TTY: 1-800-735-2922) for more information about covered dental care or go to www.denti-cal.ca.gov
Diabetes Prevention Program
Doctor visits
Durable medical equipment
Emergency services, including ambulance
Fitness benefit. See the Fitness benefit page for more information.
Hearing services, including hearing aids, up to $1,510 maximum allowance per member for both ears combined per fiscal year (July 1 – June 30)
Hospital stay
Lab tests, X-rays, or other medical tests
Long-term services and supports (LTSS), including Community-Based Adult Services (CBAS), and Nursing Facilities (NF). LTSS is not a benefit for SCFHP DualConnect members outside of the Santa Clara County service area
Occupational, physical, or speech therapy
Prescriptions, over-the-counter drugs, and other wellness items
Skilled nursing care
Transportation services: non-emergency medical transportation and non-medical transportation
Urgent care
Vision care: one routine exam every year (a referral may be required) and up to $200 for eyeglasses (frames and lenses) or up to $200 for contact lenses every two years. Benefits are provided through Vision Service Plan (VSP).

Referral and/or prior authorization may be required. Some services are covered only if your doctor or other network provider gets approval from us first. This is called prior authorization. For more information on which services require prior authorization, refer to the SCFHP DualConnect Member Handbook.

Cost-sharing - premiums and copays

You do not pay a monthly premium for your SCFHP DualConnect benefits.

SCFHP DualConnect members have no copays for prescription and OTC drugs on our Drug List. Covered drugs on our Drug List are in one-tier. Tier 1 drugs include generic, brand-name, and biosimilar drugs.

Learn more about benefits, cost-sharing, and applicable conditions and limitations. Refer to your SCFHP DualConnect Member Handbook.

Accessibility

You can ask for published materials for free in other formats, such as large print, braille, or audio. Call SCFHP DualConnect Customer Service for help.

If you are more comfortable speaking a language other than English, SCFHP can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
When you go to the doctor, interpreters are available 24-hours a day.
You can ask for SCFHP DualConnect materials written in other languages.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.