From Your Ventura County Health Care Plan March 2015

Q. How much supply of Specialty Medication will I get?A. You are only allowed a 1 month supply for each shipmentof medication. Every month, you will be getting yourshipment as long as your provider continues to prescribeyour medication and there is prior authorization in place.Q. How easy is it for me to order a prescription refill?A. As a reminder, Accredo will contact you before you runout of your medication to ensure prompt delivery of yournext refill. If you do not receive a reminder from Accredo,you should call Accredo directly to schedule the refillshipment before you use up your one (1) monthmedication supply. Call Accredo to find out exactly howearly they can ship your refill medication to you.Q. How long does it take for me to receive my medication?A. Medications are generally shipped within 24 to 48 hoursof Accredo receiving the prescription(s). Deliveries aremade to your home or to your provider’s office.Q. How do I get my specialty medication delivered if I willbe going on vacation?A. You need to call Accredo to arrange shipment of yourmedication either before you go on vacation or when youreturn from vacation.Q. What if I have a question about my medication?A. You will have toll-free access to Accredo’s staff of nursesand pharmacists who are experts, trained in specialtymedications.Q. Who will instruct me on how to administer mymedication?A. In addition to the provider’s instruction, Accredo’sclinical teams are available to provide assistance over thephone.Q. How much will my specialty medication cost?A. You can look up your out-of-pocket cost for anymedication (whether specialty or not) by going to theExpress Scripts website at www.express-scripts.com andcreating an online account. Or you can call ExpressScripts directly at (800) 811-0293 to find out your out-ofpocket cost for a particular medication or for help logginginto their website.Q. Is there a fee for having Accredo fulfill my prescriptionneeds?A. You will be responsible for any copayments as determinedby your benefit plan; delivery of the medication is free.Q. Where do I go to get the supplies necessary toadminister the medication?A. Accredo ships all standard supplies with the medications,if applicable.For more information about the Specialty Medicationprogram, feel free to contact one of our medicalmanagement personnel at (805) 981-5060.In the previous VCHCP Member newsletter we notified ourmembers that the Express Scripts’ Specialty MedicationManagement vendor recently migrated from Curascripts toAccredo. The process for ordering and verifying specialtymedications through Accredo is a little different than it wasthrough Curascripts.Accredo’s only business is to manage the care of patientsreceiving specialty medications. They realize that treatmentwith specialty medications can be difficult and stressful forpatients, and they do everything they can to make it as simpleas possible. They understand that each patient is different andhas different needs. When a patient first enrolls in the programwith Accredo, the first person they are contacted by is apatient care coordinator; a professional caregiver who isdedicated to making sure they receive the best possibletreatment. Coordinators work with a team of pharmacists,nurses, the prescribing physician and VCHCP to make sure themember receives optimum care.The following Q & A will assist you as a Member tounderstand the Specialty Medication process.FREQUENTLY ASKED QUESTIONSQ. What is a specialty pharmacy?A. A specialty pharmacy provides injectable, oral and infusedmedications. These complex and costly medicationsusually require special storage and handling and may notbe readily available at a local drug store. Sometimes thesemedications have side effects that require monitoring by atrained pharmacist or nurse. Accredo focuses on providingthese medications, while offering excellent clinicalservices and support to you and your caregivers.Q. What if my Provider prescribes a “SpecialtyMedication” for me?A. Most “Specialty Medications” require prior authorizationfrom the plan. Your provider will need to complete aTreatment Authorization Request and submit it to theHealth Plan for approval. Also your provider will need tocomplete a Doctor/Prescriber Prescription form along withthe prescription pad and fax these documents to Accredo.Q. How do I get started?A. When your provider prescribes a specialty medication foryou, that is the time to call Accredo toll free at (800) 8032523 to start your service. An Accredo representative willverify benefit coverage with VCHCP, assist with letters ofmedical necessity and coordinate delivery of themedications to your home or to your provider’s office.After the authorization is completed by VCHCP and theprovider sends the prescription to Accredo, you willreceive a call to set up a shipment date. You have to talkdirectly to Accredo to verify a delivery date or themedication will not be shipped. So please remember tocall Accredo back if you miss their call and they leave youa message.8

Chiropractic, Acupuncture and Vision Care Discounts and CoverageChiropracticorAcupuncture,oracombination of both up to the 15 visits withinthe Plan year.Chiropractors, andAcupuncturists will not bill the Plan directly.Did you know that certain Ventura CountyChiropractors,AcupuncturistsandOptometrists offer Ventura County HealthCare Plan (VCHCP) members discounts oncertain services? In order to qualify for thediscount(s), members must go to aparticipating provider and bring withthem their VCHCP Member ID card. Someparticipating providers may not offerdiscounts to members who have validinsurance coverage for such services. Forexample, if you have Vision Insurancecoverage, you may not qualify for thediscounts offered by some participatingOptometrists. VCHCP does not offer Visioncoverage.A full list of participating Chiropractor,Acupuncture and Optometrist providersoffering discounts is attached to theReimbursement Claim Form found on thePlan’s at:http://www.vchealthcareplan.orggo to the “For Members” page and click on“Forms” in the upper right-hand toolbar.From there you may download the“Reimbursement Claim Form”. You mayalso request a copy by calling MemberServices at (805) 981-5050 or toll-free, (800)600-8247.VCHCP members also have the followingPlanreimbursementcoverageforChiropractic and/or Acupuncture services: 20.00 per visit reimbursement to acombined maximum of 15 visits per planyear. This reimbursement amount applies to2015 Evidence of Coverage (EOC) BookletThe 2015 Evidence of Coverage (EOC)Guide is on the web. You may review anddownload this booklet online s.aspx - click on your specificbenefit plan and then select the Evidenceof Coverage (EOC) Booklet 2015 under“Documents”. You may alsorequest a hard copy bycontacting Member Servicesdirectly at (805) 981-5050 ortoll free (800) 600-8247,Monday - Friday, 8:30 a.m. 4:30 p.m.The Evidence of Coverage bookletdiscloses the terms and conditions of yourPlan’s coverage. The EOC outlines how toobtain care, including emergency andurgently needed care information, benefitssummary, summary of covered andexcluded services, prescription drugprogram information and limitations andexclusions, payment and copaymentresponsibilities, continuation of care, casemanagement and disease management,grievances and appeal rights andresponsibilities, termination of benefits andmuch more!9

Pharmacy BenefitsThe Ventura County Health Care Plan provides pharmacy coverage through a contract with a pharmacybenefit manager (PBM), Express Scripts. Members can create an online Express Scripts profile at:http://www.expressscripts.com/Express Scripts online provides access to the following information and services for Plan Members: Manage Prescriptions Health and Benefits Information Account Information View Recent Orders and Status View Prescription History The ability to search Prescription Historyby Rx # Determine financial responsibility for adrug Order a refill for an existing, unexpiredmail-order prescription Find the location of an in-networkpharmacy Conduct a pharmacy proximity searchbased on zip codeTo reach an Express Scripts Representative, call:(800) 811-0293DOWNLOAD IT TODAY!Behavioral and Substance Abuse Healthcare ServicesMembers can log into the “Life Strategies” webpage tosearch for Behavioral Health and Substance Abuse CareServices. You can also search for a Provider, review yourbenefits, claims, and more.https://www.liveandworkwell.com/memberThe Plan’s mental health and substance abuse benefitsare also available by calling the Plan’s Behavioral HealthAdministrator (BHA), OptumHealth BehavioralSolutions of California, “Life Strategies” Program at(800) 851-7407For more information, visit their website or the VCHCPWebsite at http://www.vchealthcareplan.org10

Standards for Members’ Rightsand ResponsibilitiesVentura County Health Care Plan (VCHCP) is committed to maintaininga mutually respectful relationship with its Members that promoteseffective health care. Standards for Members Rights andResponsibilities are as follows:1. Members have a right to receive information about VCHCP, itsservices, its Practitioners and Providers, and Members’Rights and Responsibilities.2. Members have a right to be treated with respect andrecognition of their dignity and right to privacy.3. Members have a right to participate with Practitioners andProviders in decision making regarding their health care.4. Members have a right to a candid discussion of treatmentalternatives with their Practitioner and Provider regardless ofthe cost or benefit coverage of the VCHCP.5. Members have a right to make recommendations regardingVCHCP's Member Rights and Responsibility policy.6. Members have a right to voice complaints or appeals aboutVCHCP or the care provided.7. Members have a responsibility to provide, to the extentpossible, information that VCHCP and its Practitioners andProviders need in order to care for them.8. Members have a responsibility to follow the plans andinstructions for care that they have agreed upon with theirPractitioners and Providers.9. Members have a responsibility to understand their healthproblems and participate in developing mutually agreed-upontreatment goals, to the degree possible.For information regarding the Plan’s privacy practices, please see the “HIPAALetter and Notice of Privacy Practices” available on our website ndex.aspx. Or you maycall the Member Services Department at (805) 981-5050 or toll free at (800)600-8247 to have a copy of this notice mailed to your home address.11

VCHCP Utilization Management uses Milliman Care Guidelines, VCHCP Medical Policies andVCHCP Prior Authorization Drug Guidelines as criteria in performing medical necessity reviews.Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, buta hard copy of an individual guideline can be provided as requested.A complete listing of VCHCP medical policies and prescription drug policies can be found derIndex.aspxTo obtain printed copies of any of our VCHCP Medical/Drug Policies or Milliman Care Guidelines,please contact Member Services at (805) 981-5050 or at (800) 600-8247.Medical Policies UpdateNew and updated medical policies are posted on The Plan’s website es.aspx and include the following:VCHCP Policy Guideline for Medical Reviews (NEW)Physician reviewers use applicable VCHCP medical policies, drug guidelines or other utilizationmanagement guidelines during review of Treatment Authorization Requests for services. In theabsence of specific VCHCP adopted guidelines, reviewers use professionally recognizedguidelines and standards of care for decision making.Availability of an Independent Medical ReviewWhen a member receives a denial,modification or delay of a medical service byVCHCP, the member has the right to appealthat denial, modification or delay in service. Amodification is a change made by the VCHCPto some part of the initial service request. Adelay in service occurs if the decision is notmade within the regulated time frame.given to the Plan. This new information canbe used in the decision making process.If the appeal request continues to be denied,then the member can also ask for anindependent medical review (IMR). This is the2nd stage of the appeal process. The requestfor an IMR is made to the Department ofManaged Health Care (DMHC). The processfor sending an appeal request to DMHC isincluded in the initial denial letter packet sentto the members. There is also information onthe member website. The information canalso be requested through Member Services.If the appeal is for a medical reason and not acontract reason, the review will be assignedby the DMHC to an outside medical careorganization for review. The decision is madewithin 30 days and DMHC’s decision is final.The 1st stage of the appeal process is withthe Plan itself. The Plan will re-review theoriginal service request. It will always bereviewed by a second doctor before adecision is made. The decision could be touphold or keep the denial, or to approve onlya part of services. Or the decision could be tooverturn the original denial. This means thatthe request would be approved. The changein a decision most often happens when newmedical information that applies to the case is12

The Cost of SmokingIf you are a smoker, you have probably calculated the financial cost of smoking. You know,you take the average cost of the pack of cigarettes, and multiply it by how many yousmoke in a week, then multiply that by a year and say, “wow, look how much money I couldsave if I quit smoking!” Unfortunately, this financial savings is usually not a good enoughincentive for people to quit smoking. So let’s look at other ways smoking costs you, notjust financially but in terms of your health: Premature aging/wrinkles Yellow teeth, gum disease Smaller, less effective lungs Early heart disease DNA damage that can lead to cancerRemember, as soon as you stop smoking, your body begins to heal. It’s never too late!VCHCP offers assistance to help members quit smoking. Here are some of the resourcesavailable: California Smoker’s Helpline 1-800-No-Butts Ventura County Public Health Services Tobacco Education & Control Program(805) 677-5225 Becomeanex.org (Interactive quit plan) Smokefree.gov Tobacco Cessation online Workshops at https://vchcp.cernerwellness.comIf you have questions about coverage, please call Member Services at (805) 981-5050Ventura County Health Care Plan’s Referral & Prior AuthorizationProcess and Services Requiring Prior AuthorizationNeed information on how and when to obtain referrals and authorization for specificservices? Please visit our website at www.vchealthcareplan.org, click on “ForMembers”, and then click on “Referrals and Prior Authorization”. This area provideslinks for members to obtain specific information on the Plan’s prior authorizationprocess, what services require prior authorization, timelines, and direct referralinformation. If you have any questions, please call Member Services at (805) 981-5050or (800) 600-8247.13

Ventura County Health Care Plan Wellness andPrevention ProgramAre you ready to take control of your health? The VCHCPWellness and Prevention Program is starting the 2015 WellnessCrusade! Complete different health related tasks to earn points.You can become a Wellness Champion in no time! This interactiveprogram allows adult members of the Plan access to onlinehealth appraisals and self-management tools. The healthappraisal is a health behavior questionnaire that calculateshealth risks for each member individually. Health appraisalresults are available immediately. Self-management articles andworkshops are then provided based on risks. This program benefits members byhelping to decrease risks and manage health conditions. Additional resourcesavailable include exercise and meal planners, healthy recipes, food logs, and acalendar of events in our community that are available. To sign up, visit:https://vchcp.cernerwellness.com, or connect from the Plan mberIndex.aspx to get started andTake Charge of Your Health Today!If you do not have access to the internet, please call VCHCP at (805) 981-5060 torequest a paper copy of the health appraisal. If you have additional questionsregarding the VCHCP Wellness and Prevention Program, please call (805) 981-5060and ask to speak with the Wellness and Prevention Program Administrator.Did you know that Ventura County has a resource number for awide variety of services to assist with different needs? 2-1-1 isa resource to help callers with counseling, food assistance,domestic violence services, employmentresources, health care, senior services, legalassistance, substance abuse services,housing, resources for parents, and muchmore! 2-1-1 is available 24 hours a day, 7 daysperweek.Yo ucanalsovisitwww.211ventura.org14

One size DOES NOT fit allMAKING A PLAN FOR ADHD TREATMENTHas your child recently been diagnosedwith attention deficit hyperactivity disorder(ADHD)? Is your child taking medicine forADHD? If so, it is important to make andkeep appointments with his or her doctor.A “one-size-fits-all” plan doesnot work for children withADHD. What works for onechild may not work foranother. You, your child, andthe doctor should talk about itand make a plan fortreatment.doctor see if t

and social factors. Nurse practitioner specialists include, but are not limited to, family nurse practitioners, gerontological nurse practitioners, pediatric nurse practitioners, obstetric-gynecologic nurse practitioners, and school nurse practitioners. Physician Assistant -A physician assistant is a person who has successfully completed an