$0 annual fee and $0 co-pays
MCE participants do not have to pay a fee for their coverage or co-pays for covered services, including prescriptions.
Payment is required for services only in these situations
- You go to a non-MCE provider for medical care that is not an emergency, without
a referral from a MCE provider or prior authorization from HPSM.
- You receive medical care that is not related to an emergency, outside of San
Mateo County
- You receive services that are not covered by MCE
- You have reached the coverage limit for a service
If you have questions about situations when you are responsible for the full cost of your medical care,
please call HPSM Member Services at 1-800-750-4776 or 650-616-2133.
San Mateo County MCE Privacy Notice
Doctor and Clinic Visits
Medically necessary services received from MCE Primary Care Provider (PCP) clinics are covered. Services
include consultation by phone (telemedicine) and preventive health care such as immunizations and health education.
Not Covered
Services related to family planning, breast and cervical cancer screening and treatment, prostate cancer
treatment and other services may not be covered. Routine dental services are also not covered.
For more information on what is covered and not covered, see Sections 8 and 9
of the Participant Handbook.
Optometry Visits and Eyeglasses
One optometry visit every two years is covered, with a referral from a PCP clinic. For eye conditions that require
visits to a specialist, PCP referrals are also required. Coverage for one pair of eyeglasses (including frames) every
two years is also included, with prior authorization from HPSM.
Coverage for prescription drugs and over-the-counter medicines
Medications prescribed by your doctor, and that are on the list of covered medications called the
MCE Formulary, are covered. Generic drugs and some brand name drugs are in the formulary.
To review the list of covered drugs, go to Prescriptions and Pharmacies.
Some over-the-counter medicines are covered in cases where they are medically necessary, and your doctor writes a prescription for their use.
Drugs that are not in the MCE formulary
If your doctor prescribes a brand medication that is medically necessary, but is not in the formulary, your doctor or
pharmacist needs to submit a Medication Request Form (MRF) to HPSM for approval of a non-formulary drug. HPSM has to approve the MRF in
order for you to receive the medication.
Inpatient hospital services at San Mateo Medical Center only
General hospital services including nursing care, medications, surgery-related services, lab work, room and meals are covered. For a
list of covered inpatient hospital services see the Participant Handbook. Prior authorization for hospital admission is required for coverage.
Hospital services from other hospitals, except for emergency care, are not covered.
Not Covered
Coverage for a private room while hospitalized is not included. Exceptions are made only in cases where it medically necessary.
Urgent & Emergency Care
Urgent care is covered only at MCE provider clinics and San Mateo Medical Center.
Medical attention for a health problem that is not a medical emergency, but that is necessary to prevent the problem
from getting worse, is covered only if received at MCE provider sites.
Examples of urgent care needs are:
- Earache
- Cough/cold
- Mild fever/rash
- Mild diarrhea
- Medicine refill
Urgent care services are not covered outside of San Mateo County, or from a non-MCE provider in the county,
without a prior authorization from HPSM.
Emergency Care is covered at any emergency room
If you are outside of San Mateo County and need emergency care, or go to an emergency room in San Mateo County
that is not an MCE provider, your services are covered.
Not Covered
You are responsible for the full costs of medical services received at an emergency room for conditions that
are not medical emergencies.