Serving Maricopa County. Phoenix Health Plan

Transcription

1 Serving Maricopa County Material ID: YR1411_136 Handbook Revised 10/16/2014

2 GENERAL INFORMATION Welcome! Thank you for choosing (PHP) We re happy to help you! (PHP) Member Services Contact us (602) or (800) TTY (800) Monday Friday 8 a.m. to 5 p.m North 16th Street, Suite 105 Phoenix, Arizona Contracted services funded in part under contract with the state of Arizona. It s a privilege to provide you and your family with quality health care. Your PHP* provider directory makes it easy for you to find doctors, specialists, urgent care centers, and pharmacies that fit your health care needs. You can also find out if a doctor is taking new patients, what language they speak or if they know American Sign Language. We are always adding new providers to our directory. Review your PHP member handbook for information and tips about your health care and PHP health care benefits. To view, print, or download our provider directory or member handbook please go to. To request a provider directory or member handbook sent to you at no cost, please contact PHP Member Services. (602) or (800) TTY (800) Monday Friday 8 a.m. to 5 p.m. At PHP we re committed to you and your family s health care needs. Please Note: * is referred to as PHP in this booklet. Primary Care Physician is referred to as a PCP in this booklet. 1

3 GENERAL INFORMATION Table of Contents GENERAL INFORMATION Welcome to (PHP) Member Services How the Plan Works Eligibility Your AHCCCS ID Card Who is Your Primary Care Physician (PCP) Obtaining Medical Services Making an Appointment Cancelling or Changing an Appointment Changing Your PCP Referrals for Specialists Continuity & Coordination of Care Nurse Advice Line Culture & Language SERVICES & BENEFITS Covered Services Excluded Benefits Limited Benefits Prior Authorization Health Risk Assessments Case Management Disease Management Programs Dental Care Under Age Adult Dental Care Vision Care Pharmacy Services Pharmacy Prior Authorization (PA) Generic Drugs Pharmacy Reimbursement Transportation Urgent Care & After Hour Care Emergency Care Hospitalization Behavioral Health Care Multi-Specialty Interdisciplinary Clinics 37 Children s Rehabilitative Services (CRS) 37 HEALTHY FAMILIES Early Periodic Screening, Diagnostic & Treatment (EPSDT) Well Visits for Members Under 21 Years of Age Newborn Visits Care for Your Children & Teens Arizona Early Intervention Program (AzEIP) Resources for Children Adult Care for Members Age 21 and Older Quitting Smoking MATERNITY & FAMILY PLANNING Maternity Care Postpartum Visits Family Planning continued on next page 2

4 OTHER INFORMATION Advance Directives Annual Enrollment Choice Changing Your Address Changes in Family Size AHCCCS Co-payments Other Insurance Dual Eligibility/Medicare Fraud & Abuse If You Get a Bill If You Move Away Out of Area Coverage Plan Change Request Member s Rights & Responsibilities Grievances Notice of Action Letters, Denials, Reductions, Suspensions & Terminations 70 Appeals Requesting a State Fair Hearing COMMUNITY RESOURCES List of Resources PHP TIPS Tips about Appointments Tips about Emergencies Tips about Well Visits for Members Under age Tips if You Are Pregnant Tips on Transportation Non-Covered Services

5 GENERAL INFORMATION Member Services Our Member Services Department is here to help you with questions or problems regarding AHCCCS covered services through PHP. Our representatives can help you choose or change your Primary Care Physician (PCP), find a pharmacy or urgent care clinic or schedule an appointment, among many other services. Our Member Services representatives are available Monday through Friday, 8 a.m. to 5 p.m. to serve you. (Prescription help is available 24 hours a day). Call: (602) in Maricopa County (800) outside of Maricopa County TTY / TDD users please call (800) Arizona Relay Service (800) Write: 7878 North 16th Street, Suite 105 Phoenix, AZ Lobby Hours: Monday Friday, 8 a.m. to 4:30 p.m. Visit: Member Services Will Help You Confirm your PHP membership Locate our PCPs, dentists & pharmacies Choose a PCP Address problems, complaints or concerns about your PCP or PHP services Keep current on coverage changes Get answers about your health care coverage Arrange transportation Get the most from your benefits Report an address change 4

6 GENERAL INFORMATION How the Plan Works (PHP) is a contracted health plan with the Arizona Health Care Cost Containment System (AHCCCS), Arizona s Medicaid agency. PHP is a managed care plan. That means we provide health care to our members through a selected group of doctors, dentists, hospitals and pharmacies. You will need to use doctors (called Primary Care Physicians or PCPs) who are part of our network. Except for behavioral health, your PCP will manage all your medical care and arrange any special treatments or appointments you need. View your PCP as the manager or gatekeeper of your medical care. Your PCP will tell you what services need approval before the service can be performed and will request an approval from PHP. If the prior approval request is denied, you will receive a letter from PHP to notify you. If you do not understand the letter, please contact Member Services. If you have any questions about a denied request, talk to your PCP about other treatment options or call PHP to file an appeal. See page 70 for more information about letters, denials reductions and appeals. For information about covered and non-covered services go to pages 15 and 76 of this member handbook. As a PHP member, your responsibilities include, but are not limited to: Knowing who your PCP is. Seeing your PCP during office hours. Using the emergency room for true emergencies, not routine care. (See page 13 for information about our Nurse Advice Line and page 32 for information about urgent care.) Calling Member Services whenever you have a question or need help. Go Online for Good Health Find a primary care physician (PCP) Pregnancy and family planning resources Health database (articles on health issues and symptom checker) Community resources Member newsletters How to file a complaint And much more Get More From Your Handbook Choose your primary care physician (PCP) Know when you and your family should see your PCP Set up a visit with your PCP Understand the services available to you Know what to do if you have a problem, complaint or grievance 5

7 GENERAL INFORMATION Eligibility If you lost your AHCCCS benefits and need help finding medical care, please call Member Services or visit for a list of lowcost clinics that offer primary care services or family planning. You may also visit for a listing in your area. If you need help finding low-cost or no-cost family planning services, call Arizona County Health Services at (800) or Arizona Family Health Partnership at (602) or (888)

8 GENERAL INFORMATION Your AHCCCS Identification Card (ID Card) When AHCCCS approves your enrollment, will mail you an AHCCCS ID card. It is very important to carry this card with you at all times and show it whenever you receive medical care. If you can t locate your AHCCCS ID card, call (602) or (800) You and each enrolled family member will receive an AHCCCS ID card. Your AHCCCS card will show your name, ID number and the name of your health plan. If the information on your card is incorrect, please call your eligibility worker and ask to change the information on your record. If you have an Arizona driver s license or state issued ID, AHCCCS will get your picture from the Arizona Department of Transportation Motor Vehicle Division (MVD). When providers pull up the AHCCCS eligibility verification screen, they will see your picture (if available) with your coverage details. QUICK TIPS Your AHCCCS ID card is for your use only. You may not let others use it. Keep your ID card with you and do not throw your card away. Show your ID card to get medical care or to pick up medicine at the pharmacy. Loaning or selling your ID card or the information on it is against the law. Misusing your card or medical ID number may result in legal actions and you could lose your AHCCCS eligibility, benefits and health care services. Important: If you do not receive your card or it is lost or stolen, call Member Services at (602) or (800) to request a replacement. 7

9 GENERAL INFORMATION Who is Your Primary Care Physician (PCP)? Your Primary Care Physician (PCP) is your assigned doctor and plays an important role in your health care. Your PCP is your main caregiver and will help you manage your health care needs. Your PCP will also send you to a specialist if needed. PHP has chosen a PCP for you with an office near you. You will receive a letter with the name, address and phone number of your PCP. There is a list of PCPs in your provider directory. If you want to change your PCP, please read through the section on page 11. Providers who speak languages other than English are noted in the provider directory. Women may select an OB/GYN as their PCP. If you have questions about your PCP, choosing a PCP or changing your PCP, please call Member Services. 8

10 GENERAL INFORMATION Obtaining Medical Services in Your Area PHP will help you find a PCP in your area. If there are no PCPs available in your area, we will help you find the PCP closest to you. You must receive your health care services in the area near your home. PHP will provide transportation to the closest pharmacy, urgent care, hospital and assigned PCP in your area if needed. Transportation is provided to and from the address you provided your eligibility worker when you applied for AHCCCS. To ensure timely transport, please report all address and phone number changes right away. See page 55 for more information about reporting changes in personal information. 9

11 GENERAL INFORMATION Making an Appointment To schedule an appointment, contact your PCP, dentist or specialist. During your appointment, be ready to ask any questions you may have about your health, medications or treatments. When you call your doctor, tell them: Your name or name of your child if the appointment is for your child Canceling or Changing an Appointment To cancel or change an appointment, call your doctor s office at least one day, or sooner, in advance. If needed, cancel or reschedule your transportation appointment. If you are unable to contact your doctor s office or need help, please call Member Services. The name of your health plan (PHP) Your AHCCCS ID number from your ID card (or your child s) 10

12 GENERAL INFORMATION Changing Your Primary Care Physician (PCP) It is important for you to find a PCP you trust and who makes you feel comfortable. Your relationship with your PCP is very important in providing the care you need. As a PHP member, you can change your PCP without changing your health plan. However, remaining with one PCP will ensure you receive personalized service for your health care needs. If you are thinking of making a change, try talking to your PCP before you change. If you change more than two times, Member Services will work with you and your PCP before making any more changes. You may request your PCP change by: Calling Member Services Writing to us at: Attention: Member Services, 7878 North 16th Street, Suite 105, Phoenix, AZ Visiting If you change your PCP, ask his or her office staff to send your medical records or copies to your new PCP. Your medical records should be sent within 10 days of your request. Reasons You May Change Your PCP Your PCP s office is too far away You don t understand what your PCP says You find another doctor who speaks your language or understands your culture You re not comfortable talking to your PCP Visit your PCP The same day if urgent care is needed If you re sick, but don t need to be seen the same day For routine visits, within 45 days 11

13 GENERAL INFORMATION Referrals for Specialists A specialist is a doctor whose practice is focused on a specific branch of medicine or surgery. An example of a specialist is a dermatologist who specializes in the diagnosis and treatment of skin problems. Your PCP manages all your medical care and determines if you need to see a specialist. If prior authorization is required, your PCP will contact PHP to receive authorization for you to see a specialist. For additional information about what services are covered with PHP please see page 15. You will receive a notice if your referral is not authorized. You Do Not Need a Referral & Can Self Refer: To see a PHP dentist if you are under 21 years of age To see an OB/GYN provider for covered routine or preventative services For behavioral health services (see page 35 for more information) Female members have direct access to a gynecologist within the Phoenix Health Plan s network without a referral from a primary care provider. Preventive services such as cervical cancer screening or referral for a mammogram are covered. Contact Member Services for more information on pap smears, mammograms and colonoscopies. Scheduling Appointments with a Specialist The same day for emergencies Within three (3) days for urgent care Within 45 days for routine or non-urgent care Please call Member Services if you cannot find a specialist or if you can t get an appointment with a specialist within these timeframes. Waiting at the Doctor s Office It is important to keep all of your appointments and arrive on time. Sometimes you may have to wait while your doctor sees other patients. If you are on time for your appointment and have to wait more than 45 minutes for the doctor (who was not busy because of an emergency) and you feel you waited too long, please call Member Services. 12

14 GENERAL INFORMATION Continuity and Coordination of Care PHP will inform you if your PCP or PCP s office is no longer in the PHP network. We will also help you change your PCP. If a specialist you see regularly leaves our network, we will inform you and help you find another one. Nurse Advice 24/7 (602) or (800) Questions about your health or your family s health can come up any time. Our Nurse Advice Line is here for you 24 hours a day, 7 days a week at no cost. When you call, a registered nurse will answer health questions, listen to your symptoms, provide health information or advise you where to get health services. Nurses can also tell you how to take care of yourself at home when you don t feel well but don t need to see a PCP. PHP members can call our Nurse Advice Line anytime, including weekends and holidays. When calling the Nurse Advice Line, be ready to give your name, AHCCCS ID number and symptoms. Please call Member Services and select the option for the Nurse Advice Line. The 24-hour Nurse Advice Line is always open when you need health advice. 13

15 GENERAL INFORMATION Culture & Language Culture is a major factor in how people respond to health care. PHP understands and values our diverse membership. We aim to ensure our services and programs respect our members traditions and customs. We offer members a choice of qualified PCPs to meet their needs in a culturally appropriate manner. In addition, we offer translation services in more than 200 languages, including American Sign Language. PHP can provide interpreters by phone at no cost to you. We can also provide an interpreter by phone at your PCP s office if one is not available to you. American Sign Language interpreters can go with you to your medical appointments. If you need an American Sign Language interpreter, please call Member Services at least four (4) days before your scheduled appointment. To request any of our printed materials in another language, larger print, on audiotape or in another format, or for a language interpreter or American Sign Language interpreter, call Member Services. 14

16 SERVICES AND BENEFITS Covered Services PHP is here to help you get the care you need. As a member of PHP, you may receive the following health care benefits. This list does not include all possible services. PHP will only pay for authorized services covered by AHCCCS. Family planning members are only eligible for family planning services. If you have any questions about covered services, please see your PCP or call Member Services. Some of the services covered by PHP include: 24-hour emergency care Birth control and contraceptives Chiropractic care (only for members under 21 years of age and Qualified Medicare Beneficiaries (QMB) members) Colonoscopy Please contact Member Services for more information on colonoscopies. 15

17 SERVICES AND BENEFITS Covered Services continued Some of the services covered by PHP include: (continued) Dialysis, supplies, diagnostic testing and medications as medically necessary Dietitian Emergency care and transportation (emergency ambulance transportation is only covered if you have an emergency medical condition) Family planning Hearing evaluations and treatment (hearing aids) for members under 21 years of age Home and Community-Based Services (HCBS) Home health services Hospice These services are covered for members who are certified by a physician as being terminally ill and having six (6) months or less to live. Immunization for adults 21 years and older as medically necessary, including diphtheria-tetanus, flu, pneumococcus, rubella, measles, hepatitis B and Pertussis. Zoster vaccine for members over 60 16

18 SERVICES AND BENEFITS Covered Services continued Some of the services covered by PHP include: (continued) HPV vaccine for men and women through age 20 Immunizations for members under age 21 (see pages for complete list) Incontinence briefs and pull-ups for members ages 3-20 who have a disability that causes incontinence Insuline pumps to give insulin throughout the day to a person as needed. Kidney dialysis Lab, X-ray and other tests Mammograms Maternity care for pregnant members, including care by a nurse-midwife Medically necessary foot care not provided by a podiatrist. Podiatrists may provide foot care for members under age 21. Most medical supplies, equipment and prosthetic devices for members under age 21. Most tube feedings and some special diet supplements Outpatient hospital and home health services 17

19 SERVICES AND BENEFITS Covered Services continued Some of the services covered by PHP include: (continued) Outpatient physical therapy For members age 21 and older, visits are limited per contract year (see page 20 for more information.) Pap smears Pedodontist (dental specialist) for children; no authorization required Prescription medicines approved by PHP or included in PHP s approved drug list (Formulary) Pregnancy terminations (abortions), when the pregnancy is the result of rape or incest, or if a physical illness related to the pregnancy endangers the health of the pregnant woman Preventive, emergent dental care and dental treatment for members under age 21 Rehabilitation services in accordance with AHCCCS rules and regulations Smoking cessation Transplants and transplant services in accordance with AHCCCS rules and regulations Urgent care Vision care for members over 21 years of age is limited and may include; eyeglasses, post-cataract surgery, and emergency eye conditions. Vision care, including eye exams and eyeglasses for members under 21 years of age Well-child visit (EPSDT care), including immunizations for members under 21 years of age 18

20 SERVICES AND BENEFITS Excluded Benefits The following services are not covered for adults 21 years and older. (If you are a qualified Medicare beneficiary, we will continue to pay your Medicare deductible and coinsurance for these services.) BENEFIT / SERVICE SERVICE DESCRIPTION SERVICES EXCLUDED FROM PAYMENT Percussive Vests This vest is placed on a person s chest and shakes to loosen mucous. AHCCCS will not pay for percussive vests. Supplies, equipment maintenance (care of the vest) and repair of the vest will be paid for. Bone-Anchored Hearing Aid A hearing aid that is put on a person s bone near the ear by surgery. This is to carry sound. AHCCCS will not pay for Bone-Anchored Hearing Aid (BAHA). Supplies, equipment maintenance (care of the hearing aid) and repair of any parts will be paid for. Cochlear Implant A small device that is put in a person s ear by surgery to help you hear better. AHCCCS will not pay for cochlear implants. Supplies, equipment maintenance (care of the implant) and repair of any parts will be paid for. Lower limb Micro-processor controlled joint/ Prosthetic A device that replaces a missing part of the body and uses a computer to help with the moving of the joint. AHCCCS will not pay for a lower limb (leg, knee or foot) prosthetic that includes a micro-processor (computer chip) that controls the joint. Orthotics A support or brace for weak joints or muscles. An orthotic can also support a deformed part of the body. AHCCCS will not pay for orthotic devices for members over the age of 21 years. Restrictions may apply, see limited benefits grid for more information. 19

21 SERVICES AND BENEFITS Excluded Benefits continued BENEFIT / SERVICE SERVICE DESCRIPTION SERVICES EXCLUDED FROM PAYMENT Emergency Dental Service Emergency services are when you have a need for care immediately like a bad infection in your mouth or pain in your teeth or jaw. AHCCCS will not cover dental services (including emergency dental services) unless the care needed is a medical or surgical service related to dental (oral) care. Covered dental services for members 21 years of age and older must be related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw. Covered dental services include examining the mouth, x-rays, care of fractures of the jaw or mouth, giving anesthesia, and pain medication and/or antibiotics. Certain pre-transplant services and prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head are also covered. Services by Podiatrist Any service that is done by a doctor who treats foot and ankle problems. AHCCCS will not pay for services provided by a podiatrist or podiatric surgeon for adults. Contact your health plan for other contracted providers who can perform medically necessary foot and ankle procedures, including reconstructive surgeries. For additional lists of non-covered services, please refer to page

22 SERVICES AND BENEFITS Limited Benefits BENEFIT / SERVICE SERVICE DESCRIPTION LIMITED SERVICES Transplants A transplant is when an organ or blood cells are moved from one person to another. Approval is based on the medical need and if the transplant is on the covered list. Only transplants listed by AHCCCS as covered will be paid. Physical Therapy Exercises taught or provided by a Physical Therapist to make you stronger or help improve movement. Outpatient physical therapy visits are limited to 15 visits per contract year (10/1-9/30) to restore a level of function. An additional 15 outpatient physical therapy visits per contract year (10/1-9/30) are covered when needed to keep a level of function or to help get a level of function. Orthotics A support or brace for weak joints or muscles. An orthotic can also support a deformed part of the body. Orthotic devices for members under the age of 21 are provided when prescribed by the member s Primary Care Provider, attending physician, or practitioner. Orthotic devices are not covered for members over the age of 21 years, except under the following circumstances: a. Halos to treat cervical fracture instead of surgery b. Walking boots instead of surgery or serial casting c. Knee orthotics for crutch dependent ambulation instead of a wheelchair. Medical equipment may be rented or purchased only if other sources, which provide the items at no cost, are not available. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered for all members over and under the age of 21 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit. The component will be replaced if at the time authorization is sought documentation is provided to establish that the component is not operating effectively. 21

23 SERVICES AND BENEFITS Prior Authorization for Medical Services Some medical services must be reviewed and approved (prior authorization) by PHP. Your doctor will send a request for prior authorization to PHP to pay for a service as a funded benefit. PHP determines which services are funded benefits according to standardized guidelines and AHCCCS benefits. To check if your request is approved or denied, call your PCP. If a service you requested is denied, we will tell your PCP and let you know the decision in writing. To make prior authorization decisions, PHP uses evidence-based, clinical practice guidelines accepted by the state and federal government, along with the AHCCCS benefits schedule. Visit for a list of services that require prior authorization. For more information about what to do if a service you asked for is denied, read Notices of Action on page 70 of this handbook. Decisions relating to prior authorization requests are made based on medical necessity. Urgent and emergency medical services never require prior authorization. 22

24 SERVICES AND BENEFITS Health Risk Assessment PHP cares about your health. We will send you a Health Risk Assessment (HRA) to ask about your health as well as make a reminder call. It is important you fill out the Health Risk Assessment and return it to us. Our medical service staff reviews your Health Risk Assessment and can assist you in managing your health through education and resources. Specific diseases and conditions they focus on include asthma, COPD (Chronic Obstructive Pulmonary Disease), diabetes, heart problems in combination with other illnesses, HIV/ AIDS, behavioral health, organ failure and high-risk pregnancy. If you need help filling out the Health Risk Assessment, please call the Case Management department at (602) Case Management PHP understands some members have special needs. Case management is a service PHP offers at no cost to you. Case Managers can help you if you have multiple medical problems and see many doctors for your condition(s), conditions, are disabled or need help with resources. Our Case Managers can help you understand your condition and arrange care with your doctors. A Case Manager will work with you and your PCP to help you get the care you need and is available at any time between visitations to assist you. Please call the Case Management department at (602) for more information. 23

25 SERVICES AND BENEFITS Disease Management Programs PHP wants to help you manage your health and offers disease management programs if you have chronic conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD). Our nurses will work with you to help you stay healthy, educate you about your condition and find the right services. You also need a yearly eye exam. It is important for you to discuss your diabetes care with your PCP. PHP s Asthma Program is designed for children and adults to help reduce the risk of asthma attacks. A nurse will work with you on how to avoid the triggers of an attack. We will also work with you or your child s PCP and school nurse to prevent asthma attacks at school. 24

26 SERVICES AND BENEFITS Dental Care Under 21 Years of Age Members under 21 years of age will be assigned to a Dental Home provider. A dental home provider is your child s dentist whose goal is to help you keep your child s teeth healthy and smile bright. Assigning your child to a dental home will help your child get the proper tooth and mouth care and start healthy habits. PHP requires children under age four (4) to see a specialist in children s dentistry, called a Pedodontist. You may contact your chosen dentist when your child reaches 1 year of age or when your child s first tooth erupts. Children under the age of 21 are assigned a dental home, just like a medical doctor. This dentist will help you manage your dental needs. PHP contracts with dental providers in your area. For additional information please visit www. or call Member Services for a published Dental Directory. How Quickly Can Your Child See A Dentist? For emergency appointments: within 24-hours For urgent appointments: within three (3) days For routine care appointments: within 45 days Please call Member Services if you cannot get an appointment with a dentist within these time frames. Recommendations for Preventive Pediatric Oral Health Care These recommendations are for the care of children who have no medical conditions and are developing normally. These suggestions may require changes for children with special health care needs. Your pediatric dentist can tell you when and how often your child should visit based on their personal oral health, please follow their recommendations. This is the dental periodicity table. The numbers represent the age of the member and the check marks indicate the recommendation for that age group. Cleaning 2 times a year with prophylaxis Fluoride Varnish Radiographic Assessment (X-Ray) 6-12 months months 2-6 years 6-12 years years *Adaptation from the American Academy of Pediatric Dentistry

27 SERVICES AND BENEFITS Dental Care Under 21 Years continued Covered dental services for members under 21 years of age include: Emergency dental care Dental exams X-rays (some limitations apply; call Member Services for more information) Dental cleaning every six (6) months Topical fluoride treatment Extractions, fillings, some sealants and crowns (with prior authorization) PHP contracts directly with dental providers and allows members to select a dentist from a published dental directory. If you need help finding a dentist please call Member Services or visit. Adult Dental Services Adult members 21 years of age and older receive no dental services, including emergency dental services, unless the procedure can be performed by a physician as well as a dentist. Vision Care Routine and emergency vision services are covered for members under 21 years of age. You do not need a referral from your child s PCP for vision services. If your child needs eye care or glasses, call Member Services. Coverage for members age 21 and older includes emergency and some medically necessary vision services only. Members with diabetes should see an ophthalmologist yearly for a retinal exam. 26

28 SERVICES AND BENEFITS Pharmacy Services When your PCP writes you a prescription, you must use a PHP-contracted pharmacy (drug store) to get your medicine. PHP has contracted pharmacies that are open 24 hours a day, seven days a week, including weekends and holidays. See your provider directory or visit for pharmacies near you or call Member Services for help. PHP covers certain prescription drugs when ordered by your PCP. Please call Member Services or visit to see PHP s approved list of covered medications (Formulary). The drug list lets your PCP know what drugs PHP covers without prior authorization. If you are having trouble filling your prescriptions after hours, on weekends or holidays, ask the pharmacy staff for the reason. Here are some common reasons why prescriptions do not go through at the pharmacy and what to do: REASON The drug requires prior authorization. The prior authorization has expired. Not enough information about other insurance you might have. Refill too soon Quantity limits Medication restrictions Prescriber restrictions FIRST ACTION Your medical provider needs to fax a prior authorization request to PHP. Please contact your medical provider The pharmacy can call PHP for a onetime approval extension. but your medical provider will still have to send in a prior authorization renewal request for more refills. You will need to provide the pharmacy with your other insurance card. You are filling your prescription too soon. The pharmacy can usually fill for a lesser quantity, but you will need to contact your medical provider for a prior authorization for the larger quantity. Call Member Services Call Member Services If you have hospital discharge prescriptions or prescriptions from an emergency department, the pharmacy can call PHP 24 hours a day for a seven-day supply override. Please contact us if you have any questions or trouble filling a prescription at the pharmacy. PHP Member Services can help you with your prescriptions 24 hours a day, seven days a week, including weekends and holidays. 27

29 SERVICES AND BENEFITS Pharmacy Prior Authorization (PA) Because some drugs require prior authorization (PA), ask your PCP if your prescription requires one. If it does, ask if there is another medicine that does not require prior authorization. Your PCP can decide if you need a nonpreferred drug. If so, your PCP must give PHP a request for prior authorization. A standard request can take up to 14 days. If PHP does not approve the request, we will notify you. Your Doctor Writes a Prescription What s Next? Ask the doctor if the drug is on PHP s drug list (Formulary) Ask how much medicine you should take Ask how long you should take the medicine and how to get a refill Ask what you should do if you have a bad reaction to the medicine To Get Your Prescriptions Filled Go to a PHP contracted pharmacy Give the pharmacy your prescription Show your AHCCCS ID card If you have other insurance, tell the pharmacy and show them your card Call PHP s Member Services if you have questions about filling your prescriptions 28

30 SERVICES AND BENEFITS What are Generic Drugs? Generic drugs are made with the same active ingredients, strength and dose as their brand-name counterparts. The difference is how the drug looks, its shape, color, flavor or name. A generic drug is as safe and effective for patients of all ages as the brand-name drug. As a group, generic drugs have no proven age-related side effects different from the brand name drugs. Generics have been shown to be as safe as brand-name drugs and work the same in children or the elderly. The same manufacturing standards have to be met by both generic and brand manufacturers. The Food and Drug Administration (FDA) inspects all United States (U.S.) drug manufacturers and recalls any marketed drugs that do not meet standards. The FDA requires generics to have the same quality, strength, purity and stability as brand names. The U.S. government strictly regulates both brand name and generic drugs made and bought in the U.S. Drugs made in other countries, unless inspected by the FDA, do not have to adhere to the same manufacturing standards as those in the U.S. 29

31 SERVICES AND BENEFITS Pharmacy Reimbursement You may be eligible for reimbursement if the medicine is covered or authorized by PHP or you had prior period coverage before joining PHP and you paid out of pocket. We will only reimburse you for what PHP would have paid for the medication, which may be less than what you paid at the pharmacy. Call Member Services and request a reimbursement form. You will submit your pharmacy and cash register receipt for reimbursement. All receipts must be submitted within six (6) months from the date of purchase. Please call Member Services for more information about pharmacy reimbursement. 30

32 SERVICES AND BENEFITS Transportation PHP provides medically necessary, non-emergency transportation for members with no other means to get to medical appointments. Before you call PHP for transportation you must: Try to use your own car Ask a friend or family member to give you a ride Use public transportation (bus or light rail), if available in your area Transportation - Guidelines Rides are given only for health care visits covered by PHP Call Member Services three (3) days in advance to schedule transportation If you can ride the bus, we will send you bus tickets at no cost. In some cases, if you are not medically able to take the bus or are outside a bus line, we will arrange another type of transportation. If you have a special need, such as a wheelchair or oxygen, please let us know. We will pick you up and return you to the residence address you provided your eligibility worker. Transportation is provided to the member who has the appointment and a parent if the member is a minor. Arrangements will be made if you need special assistance or must have another adult with you. Members transported by cab must: Have their own car seat for children under 8 years of age Be ready at your scheduled pick-up time and pick-up place Call us to cancel your ride if you find another one, or if you change your appointment If you are traveling a long distance, you may be picked up more than one hour prior to your appointment to make sure you arrive on time. You should not have to arrive more than one hour before your scheduled appointment or wait more than one hour for your transportation home. 31

33 SERVICES AND BENEFITS Transportation continued PHP s transportation provider is contracted to provide members transportation to and from medical services only. They are not contracted to stop at grocery or other stores or deliver packages. Please be considerate of your driver and understand these services are not covered. PHP will provide transportation to CRS appointments and your first behavioral health intake visit, if needed. Call your behavioral health provider for transportation to all follow-up visits or to arrange for pick-up of behavioral health medications. You have the right to file a complaint (grievance) if you are dissatisfied with the transportation services. See page 69 for additional information about grievances. Emergency transportation, including an ambulance, is a covered benefit if you have a medical emergency. Urgent Appointment If you need to see your PCP because of a sudden or urgent condition, please contact Member Services to arrange a ride. Emergency Transportation In a life-threatening situation, use the emergency medical services (EMS) available and/or activate EMS by dialing An ambulance is not to be used to take you to the Emergency Room for routine problems, such as earaches, colds, the flu or sore throats. 32

34 SERVICES AND BENEFITS Urgent Care & After-Hours Urgent Care Urgent care is needed when you have an injury or illness that must be treated within 24 hours. It is not life threatening, but you cannot wait for a routine visit with your PCP; urgent care is not emergency care. If you have a sudden health problem that is not an emergency, call your PCP. Listen carefully, as you may be asked to leave a message so your PCP can call you back if it is a weekend, evening or holiday. (Remember, you can also call the Nurse Advice Line 24 hours a day at no cost. A nurse can answer your questions and advise you where to go.) If your PCP cannot see you, you may be directed to an urgent care center. For a list of urgent care centers see your provider directory, visit or call Member Services. GO TO URGENT CARE IF YOU: Have a Sore Throat A Cut Needing Stitches Have a Condition that Is NOT Life Threatening 33

35 SERVICES AND BENEFITS Emergency Care An emergency means a medical condition with severe symptoms, including severe pain that without immediate care could result in: a) Serious jeopardy to your health, or to the health of your unborn child, if pregnant b) Serious impairment of bodily functions If you have a medical or life-threatening emergency, go to the nearest hospital in or out of network or dial 911. No authorization is required for emergency services. You have a right to go to any hospital or other emergency room facility for emergency services. Emergency transportation, including an ambulance, is a covered benefit if you have a medical emergency. When you receive emergency care, make sure to show your AHCCCS ID card. Be sure to follow any instructions you receive about seeing your PCP or a specialist after you have received emergency care. GO TO THE EMERGENCY ROOM IF YOU HAVE: Trouble Breathing Chest Pain Seizure(s) Broken Bone(s) Hospitalization Your PCP will make all arrangements for you if you need to go to the hospital and it s not an emergency. Both your PCP and PHP must approve your hospital visit before you are admitted. 34

36 SERVICES AND BENEFITS Behavioral Health Care Behavioral health care includes evaluation and treatment and support services for both mental disorders and substance abuse. These services can help you with problems like: Simple anxiety Depression Attention Deficit Hyperactive Disorder (ADHD) Drug or alcohol abuse Members are covered for crisis behavioral health services. AHCCCS members are entitled to a wide-range of behavioral health benefits provided by the Regional Behavioral Health Authority (RBHA). You do not need a referral from your PCP to receive behavioral health services. The services may include: Behavioral Health Case Management Behavior management personal care, family support/home care training, peer support Psychotropic medications Psychotropic medication adjustment and monitoring Behavioral health nursing services Emergency behavioral health care Emergency/non-emergency transportation Evaluation and assessment Individual, group and family counseling Inpatient hospital services Laboratory and radiology services for psychotropic medication regulation and diagnosis Living skills training, health promotion, services to support your employment Opioid Agonist treatment Non-hospital inpatient psychiatric facilities services (level 1 residential treatment centers and sub-acute facilities) Respite care (with limitations) Rural substance abuse transitional agency services Screening, evaluation and assessment Home care training to home care client Partial Care (supervised day program, therapeutic day program and medical day program) Psychosocial rehabilitation (living skills training, health promotion; supportive employment services) 35

37 SERVICES AND BENEFITS Behavioral Health Care continued Your ID card has a phone number to access behavioral health and substance abuse services. You will be assigned to a provider based on where you live. If you have questions or need help getting behavioral health services, please call the number on your card. The provider (RBHA) will pay for most behavioral health services including most prescriptions for behavioral health conditions. For behavioral health emergencies, call 911 or call the crisis lines listed on this page. The Maricopa Crisis Line (602) (toll free) Hearing Impaired TTY/TDD Maricopa County Regional Behavioral Health Authority (RBHA) Mercy Maricopa Integrated Care (MMIC): Member Services: or Member Services for the Hearing Impaired: (TTY/TDD) 711 When to Contact PHP Behavioral Health Staff? You should contact PHP behavioral health staff to assist with your transition of care in the following situations: You are enrolling with the RBHA for behavioral health services. You have completed your behavioral health treatment for diagnoses of depression anxiety or ADHD through the RBHA and are working with you RBHA provider to transition back to your PCP. PHP behavioral health staff is available to assist with referral, coordination of care or your transition needs. If you need help with any of these services call us at (602) If you receive covered behavioral health services from the RBHA and need help getting to appointments, contact the Maricopa County RBHA. If necessary, PHP will help with transportation to your first intake appointment. In addition, when you are enrolled through Maricopa County RBHA, your medications are prescribed and managed by your RBHA provider rather than your PCP. If you have any questions, or if you are not sure if you or your family members qualify for behavioral health services, please call your PCP or the PHP Behavioral Health Coordinator at (602) or (800) , ext or Member Services. 36

38 SERVICES AND BENEFITS Children s Rehabilitative Services (CRS) Children enrolled with CRS will obtain their physical and behavioral health services from United Healthcare Community Plan (UHCCP). This program specializes in health care services for children with chronic or disabling health conditions. Members may choose to continue enrollment with the CRS program when turning 21, CRS will continue to be responsible for payment of CRS conditions If your child has a covered CRS condition, your primary care provider or PHP may refer them to AHCCCS to determine if they are eligible. If you have other primary insurance you are not required to utilize the CRS program. If you use your primary insurance or Medicare for CRS covered conditions, PHP will pay your deductibles and co-pays as a secondary insurance. Once you have maxed out of your primary insurance or Medicare benefit, PHP will refer your child to AHCCCS for a determination of CRS eligibility. If you do not have other primary insurance coverage and you refuse to apply for or enroll in the CRS program when your child is eligible, and your child receives CRS covered services, you may be billed by the provider for the CRS services provided. For more information about this program or assistance on how to make, change or cancel an appointment with your CRS Clinic Provider/Provider, please contact UHCCP at (800) or call Member Services Department at (602) or toll free at (800) For CRS advocate support contact, United Healthcare Community Plan/CRS Ombudsman/Member Advocate at (602) Multi-Specialty Interdisciplinary Clinics (MSIC) Multi-Specialty, Interdisciplinary Clinics (MSIC) are established facilities where specialists from multiple disciplines meet with Members and their families for the purpose of providing interdisciplinary services to treat members condition(s) all at one location and sometimes at the same appointment. The services offered by MSIC may include primary care, specialty and behavioral health services. PHP may discuss assigning you to one of these clinics to better meet your healthcare needs. Our contracted MSIC clinics offer the following specialties: Primary Care (Pediatrics, Family Practice and Internal Medicine); Obstetrics and Gynecologists; Pulmonologists; General Surgeons; Cardiologists; Behavioral Health; and Dental providers. To make, change and cancel an appointment with a contracted MSIC, contact the clinic at the appointment scheduling number. 37

39 HEALTHY FAMILIES Early Periodic Screening, Diagnostic and Treatment (EPSDT) Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention and treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS state plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDT services. A well child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and dental periodicity schedules. Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening services, vision services, dental services, hearing services and such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the (AHCCCS) state plan. 38

40 HEALTHY FAMILIES Early Periodic Screening, Diagnostic and Treatment (EPSDT) continued This means that EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within one of the 28 optional and mandatory categories of medical assistance as defined in the Medicaid Act. Services covered under EPSDT include all 28 categories of services in the federal law even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective. EPSDT includes, but is not limited to, coverage of inpatient and outpatient hospital services, laboratory and x-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive and rehabilitative services. However, EPSDT services do not include services that are experimental, that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions. 39