Healthy Options with Community Health Plan of Washington

Transcription

1 Your Benefits Healthy Options with Community Health Plan of Washington Including: Benefits covered by Community Health Plan Benefits covered by fee-for-service Benefits not covered Prescription drug services About prior authorizations and referrals What to do if you get a bill UPDATED: July 1, 2012

2 Contact Information Healthy Options with Community Health Plan of Washington Community Health Plan Contacts CUSTOMER SERVICE Hours Monday Friday 8:00 am 5:00 pm Voice toll free TTY Relay Dial OFFICE PHONE voice WEB MAILING ADDRESS Community Health Plan of Washington 720 Olive Way, Suite 300 Seattle, WA FIND COMMUNITY HEALTH PLAN PROVIDERS On the chpw.org website, select the Our Providers tab and then select the kind of search you want. Contact the Community Health Plan customer service team. Contacts Outside Community Health Plan HEALTHY OPTIONS (MEDICAID) Web hrsa.dshs.wa.gov/healthyoptions/ Your Medical Benefits handbook althyoptions.htm Medicaid customer service phone Voice TTY Relay Dial WASHINGTON STATE To learn about your rights under the law, call the Washington State Office of the Insurance Commissioner: If you have a problem or concern, call the Washington State Department of Health Consumer Hotline: FREE 24-HOUR NURSE ADVICE LINE Voice toll free TTY toll free Your Healthy Options Benefits Page 2

3 Table of Contents Your Benefits... 4 If You Get a Bill for Covered Services... 4 About Healthy Options Benefits... 5 Benefits and Services Covered by Community Health Plan of Washington... 5 Benefits Covered by Fee-For-Service... 9 Note about discontinued services Some Services Are Excluded and NOT Paid For Prescription Drug Services To find a pharmacy Formulary To get a formulary (list of approved drugs) Nonformulary and prior authorization requests Your Right to Safe and Effective Pharmacy Services Frequently Asked Questions About Pharmacy About Prior Authorizations and Referrals To make sure you don't get a bill you're not expecting, please read these notes carefully: What Is a Referral? When Do I Need to Get a Referral? What Is a Prior Authorization? When Do I Need to Get a Prior Authorization? Prior Authorization List HOW TO GET MORE INFORMATION Your Healthy Options Benefits Page 3

4 Your Benefits This booklet is a summary of services and treatments covered by Community Health Plan of Washington ("Community Health Plan" or "the Plan") and the Washington State Health Care Authority (HCA) for Healthy Options. Some health care services are not covered. Some services are limited by number of visits or supply/equipment items. The Plan has a process to review your or your provider s request for an excluded or limited service as a Limitation Extension or for a medically necessary noncovered service as an Exception to Rule. If you have a question about a benefit or service, call the Community Health Plan customer service team at , Monday Friday 8:00 am 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial If You Get a Bill for Covered Services If you get a bill for services that you think are covered by Healthy Options, send the bill directly to Community Health Plan at: CHP Claims PO Box Plano, Texas You have no copays (a set amount you pay) for covered services. But if you get a service that is not covered by Community Health Plan or by fee-for-service, you might have to pay. To make sure you are not billed: Always carry both your Services card and your Community Health Plan of Washington ID card. Know the name of your health plan and your primary care provider (PCP). Know the Plan's rules. If you do not follow rules such as these, you may be billed: The service must be covered. Services and treatments are covered only if medically necessary. For more information, see the Community Health Plan website ( Click the Our Plans tab and click Healthy Options. Click the link to How to Find Important Information and then follow the link to the page about Utilization Management. You must get services from providers in the Community Health Plan network, except in emergencies or if you get an approval beforehand. You need a referral from your primary care provider to go to a specialist. Some services require a prior authorization (okay by the Plan) before you get the service. If you get a service before you get a referral or an authorization, you might have to pay for it yourself. Your Healthy Options Benefits Page 4

5 If you have a question about a specific service, ask your provider or call the Community Health Plan customer service team at , Monday Friday 8:00 am 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial About Healthy Options Benefits If you do not find a service in the "Benefits and Services Covered by Community Health Plan of Washington" list, please check these lists: "Benefits Covered by Fee for Service" "Services Excluded and Not Paid For" Benefits and Services Covered by Community Health Plan of Washington Covered Benefit: Ambulance services Details: For emergencies only or when transporting between facilities. Covered Benefit: Antigen (allergy serum) Details: Allergy shots Covered Benefit: Audiology tests (Hearing tests) Covered Benefit: Biofeedback therapy Details: When medically necessary for incontinence. Requires a prior authorization for more than 6 visits. Covered Benefit: Birth control: See "Family planning services." Covered Benefit: Birth defects: See "Cosmetic surgery." Covered Benefit: Blood products Details: Includes blood, blood components, human blood products, and their administration. Covered Benefit: Breast pumps Covered Benefit: Chemotherapy Covered Benefit: Chiropractic care for children Details: Benefit is for children only (age 20 and younger) with referral from PCP after well child screening. For more than 12 visits requires prior authorization. See "Osteopathic manipulative therapy." Covered Benefit: Contraceptives: See "Family planning services." Your Healthy Options Benefits Page 5

6 Covered Benefit: Cosmetic surgery Details: Covered ONLY WHEN the surgery and related services and supplies are provided to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for postcancer treatment. Covered Benefit: Diabetic supplies Covered Benefit: Dialysis Covered Benefit: Emergency services Details: Available 24 hours per day, 7 days per week anywhere in the United States. An emergency is when someone has a serious medical problem and needs care right away. Covered Benefit: EPSDT (Early Periodic Screening, Diagnosis, and Treatment) Details: EPSDT includes regular checkups to make sure people younger than 21 get the preventive care they need to catch and treat health problems at an early stage. Screenings (well child care) include: Complete physical exam with health, mental health screening, and developmental history Immunizations (shots) and lab tests Screens for vision; hearing; dental care; mental health; and substance abuse Covered Benefit: Eye exams Details: Must use the Plan s provider network. Limited to one exam every 24 months for adults 21 and older, and every 12 months for children age 20 and younger. Can be more frequent if the Plan decides it is medically necessary. Note: HCA covers eyeglasses, contact lenses, and hardware fittings only for members age 20 and younger on a fee-for-service basis. Covered Benefit: Family planning services Details: You can choose to go to a Family Planning Clinic or the local health department, or you can use the Plan's provider network. Covered Benefit: Fluoride treatment prescription (liquid or tablets) Details: When prescribed by a physician (PCP) after well child screening. Covered Benefit: Health care services (including office visits, preventive care, specialty care) Details: Must use the Plan s provider network. For specific questions about referrals and prior authorizations, call Community Health Plan customer service. Covered Benefit: Health education and counseling Details: Examples: Health education for conditions such as diabetes and heart disease. Your Healthy Options Benefits Page 6

7 Covered Benefit: Hearing exams Details: Hearing exams by the Plan's provider network. Note: HCA covers hearing aids only for members age 20 and younger on a fee-for-service basis. Covered Benefit: HIV/AIDS screening Details: You can choose to go to a family planning clinic, to the local health department, or to your PCP. Covered Benefit: Home health care Details: Requires prior authorization. Covered Benefit: Hospice or end-of-life care Details: Requires prior authorization. Covered Benefit: Hospital inpatient and outpatient services Details: Inpatient requires prior authorization for all non-emergent care. Some outpatient services may require prior authorization. Covered Benefit: Immunizations and vaccinations Covered Benefit: Lab and X-ray services Details: MRI and MRAs require prior authorization. Some radiology services require prior authorization Covered Benefit: Mammograms: See "Women's health care." Covered Benefit: Maternity and prenatal care: See "Women's health care." Covered Benefit: Medical equipment and supplies: Details: When medically necessary. Prior authorization is required, depending on the item and for ANY equipment or supply whose value is $1,000 or more on the HCA fee schedule. For more information, see your provider or call Community Health Plan customer service. Covered Benefit: Mental health, outpatient treatment Details: Limited benefit based on medical need. The benefit through the Plan covers: Up to 12 hours of treatment per calendar year for adults. Up to 20 hours of treatment per calendar year for children. Mental health medication management by your PCP or mental health provider. Children younger than 5 being prescribed mental health medication must have a second opinion from a psychiatrist to approve the medication. Psychological testing and evaluation once every 12 months for adults 21 and older, or as needed if identified by a well child screening for children 20 years old and younger. Covered Benefit: Nutritional counseling: See "Health education and counseling." Your Healthy Options Benefits Page 7

8 Covered Benefit: Occupational therapy Details: Covered for both rehabilitation and developmental reasons. Requires a prior authorization for more than 12 visits. HCA covers the occupational therapy on a fee-for-service basis when provided to members age 20 and younger in an approved Neurodevelopmental Center. To find a center, see: Covered Benefit: Organ transplants Details: Tissue and organ transplants when medically necessary. Requires prior authorization. Covered Benefit: Osteopathic manipulative therapy Details: Limited to 10 osteopathic manipulations per calendar year when performed by a Plan network Doctor of Osteopath (DO). Covered Benefit: Oxygen and respiratory services Details: Require prior authorization. Covered Benefit: Pharmacy services Details: Must use participating pharmacies and the Community Health Plan formulary. See "Prescription Drug Services" in this booklet. Covered Benefit: Physical therapy Details: Covered for both rehabilitation and developmental reasons. Requires a prior authorization for more than 12 visits. HCA covers physical therapy on a fee-for-service basis when provided to children in an approved Neurodevelopmental Center. To find a center, see: Covered Benefit: Podiatry Details: No prior authorization required. However, you do need a referral from your primary care provider. Covered Benefit: Pregnancy terminations, involuntary (miscarriage) Covered Benefit: Private duty nursing Covered Benefit: Radiology and medical imaging services Details: MRI and MRAs require prior authorization. Some radiology services require prior authorization. Covered Benefit: Reconstructive surgery after mastectomy Details: Requires a prior authorization for non-cancer related reconstruction. Covered Benefit: Sexually transmitted diseases (STD) treatment Details: You can choose to go to your PCP, to the local health department, or to a family planning clinic. Your Healthy Options Benefits Page 8

9 Covered Benefit: Skilled nursing facility (SNF) Details: Requires a prior authorization. Covered Benefit: Smoking cessation Details: Covered as prescribed. For details, contact Community Health Plan customer service. Covered Benefit: Speech therapy Details: Covered for both rehabilitation and developmental reasons. Requires a prior authorization for more than 12 visits. HCA covers the speech therapy on a fee-for-service basis when provided to children in an approved Neurodevelopmental Center. To find a center, see: Covered Benefit: Spinal manipulations: See "Osteopathic manipulative therapy." Covered Benefit: Sterilizations, age 21 and older Details: Must complete sterilization form 30 days prior or meet waiver requirements. Reversals not covered. Covered Benefit: Tuberculosis (TB) screening and follow-up treatment Details: You can choose to go to your PCP or to the local health department. Covered Benefit: Women's health care Details: Must get services from the Plan's provider network. Includes follow-up treatment for problems discovered. You can choose to get some services from your PCP clinic or go directly to a local health department or family planning clinic. You do not need a referral from the Plan for: Family planning services and birth control HIV and AIDS testing Immunizations Sexually transmitted disease treatment and follow-up care TB screening and follow-up care Benefits Covered by Fee-For-Service The following benefits and services are covered by fee-for-service. Community Health Plan and your PCP can help coordinate your care with other community-based services and programs. If you do not find a service in the "Benefits Covered by Fee for Service" list, please check these lists: "Benefits and Services Covered by Community Health Plan of Washington" "Services Excluded and Not Paid For" Your Healthy Options Benefits Page 9

10 Fee-for-Service Benefit: Alcohol and substance abuse services, inpatient, outpatient and detoxification Details: Services must be provided by DSHS certified agencies. For specific information, call Fee-for-Service Benefit: Community and home-based services for older and physically disabled persons such as COPES and personal care services Details: These services must be approved by the Aging and Disability Services Administration (ADSA). Call Fee-for-Service Benefit: Dental services Details: Only for members 20 and younger, except for emergency oral care. You must find a provider who will bill HCA. Fee-for-Service Benefit: Early Support for Infants and Toddlers (ESIT) for children from birth to age 3 Details: Call for information. Fee-for-Service Benefit: Eyeglasses and fitting services Details: Only for members 20 and younger. You must find a provider who will bill HCA. Fee-for-Service Benefit: Hearing aid devices Details: Only for members 20 and younger. You must find a provider who will bill HCA. Fee-for-Service Benefit: Maternity support services Details: Part of First Steps Program. Call Fee-for-Service Benefit: Mental health, inpatient psychiatric care, and crisis services Details: Inpatient care must be authorized by a mental health professional at the local Community Mental Health Agency. For more specific information call Fee-for-Service Benefit: Prenatal genetic counseling Fee-for-Service Benefit: Pregnancy terminations, voluntary Details: Includes termination and follow-up care for any complications. Fee-for-Service Benefit: Sterilizations, younger than 21 Details: Must complete sterilization form 30 days prior or meet waiver requirements. Reversals not covered. Fee-for-Service Benefit: Transportation, for medical appointments Details: HCA pays for transportation to get you to and from needed non-emergency health care appointments. If you have a current Services card, you may be eligible for transportation. Your broker will arrange the most appropriate, least costly transportation for you. Your Healthy Options Benefits Page 10

11 For a list of transportation brokers and their phone numbers, see: Fee-for-Service Benefit: Weight loss or reduction surgery Details: Gastric bypass only. Must be approved by the HCA fee-for-service program. Note about discontinued services The following services are no longer available through HCA or Community Health Plan for adults age 21 and older: Eyeglasses and fitting services Hearing aid devices Some Services Are Excluded and NOT Paid For The examples in the list below are called exclusions, meaning these services are not covered, even if medically necessary. These services are not covered by the Plan or by fee-for-service. If you get these services you may have to pay for them yourself. If you do not find a service in the "Services Excluded and Not Paid For" list, please check these lists: "Benefits and Services Covered by Community Health Plan of Washington" "Benefits Covered by Fee for Service" Excluded Service: Alternative medicines Details: Such as acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, or naturopathy. Excluded Service: Chiropractic care for adults Excluded Service: Cosmetic or plastic surgery Details: Such as tattoo removal; face lifts; ear or body piercing, hair transplants. Excluded Service: Diagnosis and treatment of infertility, impotence, and sexual dysfunction Excluded Service: Gender reassignment surgery Excluded Service: Marriage counseling and sex therapy Excluded Service: Personal comfort items Excluded Service: Nonmedical equipment, such as ramps or other home modifications Excluded Service: Physical exams needed for employment, insurance, or licensing Your Healthy Options Benefits Page 11

12 Excluded Service: Services not allowed by federal or state law Excluded Service: Weight reduction and control services Details: Includes weight loss drugs, products, gym memberships, or equipment for the purpose of weight reduction. Prescription Drug Services The Community Health Plan of Washington pharmacy network includes pharmacy chains and neighborhood drug stores. You must get your prescription filled at a pharmacy in the Community Health Plan network. You can get up to a 30-day supply of prescribed drugs at a participating retail pharmacy. Community Health Plan does not have a mail order pharmacy benefit. To find a pharmacy Visit the Pharmacy Search online: On the Community Health Plan website ( select the Our Providers tab and then select Pharmacy Search. Phone the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Formulary Community Health Plan of Washington uses a formulary system, which means we usually only pay for approved drugs. A group of providers and pharmacists develops this list of approved drugs based on safety, effectiveness, and cost. For more information about requests for nonformulary drugs, see "Nonformulary and prior authorization requests." Community Health Plan cares about your safety. That is why we do not cover certain types of medications, such as experimental drugs and drugs that have not been approved by the government. We also have limits, such as quantity limits, to help you use your medicine safely. To get a formulary (list of approved drugs) To find out which drugs are covered on the Community Health Plan formulary, visit the Formulary Search online: On the Community Health Plan website ( select the Our Providers tab and then select Formulary Search. To find out about a specific drug or to get the Community Health Plan Formulary booklet, contact the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Your Healthy Options Benefits Page 12

13 If you have any questions about our formulary or why we limit or will not pay for drugs that are not on the approved list (the formulary), please call the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or If you are hearing or speech impaired, please call TTY Relay: Dial Nonformulary and prior authorization requests If you need a drug that is not covered or requires prior authorization, your provider may ask us to pay for it. Your provider request does not guarantee that we will pay for the drug your provider asks us to pay for. Your provider must call or send nonformulary and prior authorization requests to: Express Scripts, Inc. Attn: Prior Authorization Mail Stop B Evans Road St. Louis, MO Phone: Your Right to Safe and Effective Pharmacy Services State and federal laws set rules for safe and effective pharmacy services. These laws give you the right to know what pharmacy services are paid for by your plan. If you would like more information about what pharmacy services are paid for by Community Health Plan of Washington, call the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial Frequently Asked Questions About Pharmacy 1. Does this plan limit or exclude certain drugs my health care provider might prescribe? The Community Health Plan of Washington drug formulary is formed by an independent Pharmacy and Therapeutics (P&T) Committee. This P&T Committee is made up of Washington State providers and pharmacists from various medical specialties. The P&T Committee members review medications based on safety, effectiveness, and cost, selecting the products that show the most value in each class. Community Health Plan's formulary is a mandatory generic formulary. This means that the brand-name product will not be paid for without first trying the formulary generic product. Your Healthy Options Benefits Page 13

14 2. When can my plan change its drug formulary list? If a change occurs, will I have to pay more to use a drug I had been using? The Community Health Plan P&T Committee reviews the formulary several times each year to make sure Community Health Plan covers needed drugs. When the formulary is updated, changes are posted online ( In most cases, you will get written notice 60 days before Community Health Plan removes your drug from the formulary. 3. What should I do if I want a change from limitations or exclusions for drugs specified in this plan? Your PCP should call Community Health Plan's pharmacy benefit manager, Express Script, Inc. (ESI), at , 24 hours a day, seven days a week, to ask for formulary exceptions such as quantity limit changes and nonformulary drugs. A decision might be made during the call for both normal circumstances and emergency medical conditions. The decision may take up to 3 business days. 4. What should I do to ask for a drug excluded by my medical plan? If your drug won't be paid for when you try to fill the prescription at the pharmacy, you have the right to appeal. If you want to appeal, please call the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Do I have to use certain pharmacies? Yes. Community Health Plan works with more than 1,000 participating pharmacies in Washington State. To learn which pharmacies work with Community Health Plan: Visit the Pharmacy Search online: On the Community Health Plan website ( select the Our Providers tab and then select Pharmacy Search. Phone the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial How many days' supply of most medications can I get? What if I'm traveling? You can get up to a 30-day supply of prescribed drugs. Your Healthy Options Benefits Page 14

15 If you need a 30-day supply of a prescription before you leave on a planned trip away from our service area, please ask your PCP before you leave. If you need more than a 30-day supply, please call the Community Health Plan customer service team at the number below. For more information, please call the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial What other pharmacy services does my health plan pay for? The pharmacy services only pay for formulary medications, unless the Plan agrees to pay for the nonformulary drug. To find out more about your rights under the law, call the Washington State Office of the Insurance Commissioner at If you have a problem or concern about the pharmacist or pharmacy serving you, please call the Washington State Department of Health at About Prior Authorizations and Referrals Community Health Plan of Washington is a managed care health plan. This means that your primary care provider (PCP) and the Plan coordinate all of your care. You need to get services, drugs, equipment, and supplies from your PCP or another provider in our network. For some services, drugs, and supplies you need to get a prior authorization from the Plan. You may also need a referral from your PCP to see other providers. Most medically necessary specialist services are covered by your plan. Talk to your PCP, who may submit a referral to an in-network provider or submit a referral to an out-of-network provider if an in-network provider is not available. Some services, whether from an in-network or out-of-network provider, require a prior authorization from the Plan as well. To see a list of participating providers and specialists, including their location, languages spoken, and availability: Visit the Pharmacy Search online: On the Community Health Plan website ( select the Our Providers tab and then select the type of search you want. To get a printed report or have someone search for you, contact our customer service team. Contact the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial A referral from your PCP is not the same as a prior authorization. For more information and to avoid charges you might have to pay for yourself, please see "What Is a Referral?" and "What Is a Prior Authorization?" Your Healthy Options Benefits Page 15

16 To make sure you don't get a bill you're not expecting, please read these notes carefully: In most cases, if Community Health Plan does not approve a referral to a provider outside our network before you see the provider, the Plan will not pay for the service. If you get a service on the Prior Authorization List without getting the authorization first, the Plan will not pay for it. This may include other services related to a service you got that was not authorized. To make sure you have the most current list of what requires approval before the service and to avoid charges you don't expect, always ask your PCP or call our customer service team before you get a service or supplies. Contact the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial What Is a Referral? A referral is when one provider sends a patient to another provider, usually a specialist, for diagnosis and treatment. Before you see a specialist or another provider, talk to your primary care provider. A referral is good only until the end of the period okayed by Community Health Plan. If you have a complicated or serious medical problem, you have the right to a referral that lasts for a longer period of time than a regular referral. This is called an extended (standing) referral. An extended referral, like a regular referral, is good only until the end of the period okayed by Community Health Plan. To get a referral, you must talk to your PCP. Your PCP tells us: Which provider the PCP refers you to. The length of time and number of visits your PCP says you may use the provider's services. When Do I Need to Get a Referral? Except in emergency care, if you get services or treatment from a provider outside our network without first getting a referral from your PCP, the Plan will not pay for it. To see a list of participating providers and specialists, including their location, languages spoken, and availability: Visit the Pharmacy Search online: On the Community Health Plan website ( select the Our Providers tab and then select the type of search you want. To get a printed report or have someone search for you, contact our customer service team. Phone the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Your Healthy Options Benefits Page 16

17 You do not need your PCP's referral for: Emergency services, which also do not require a prior authorization. Routine and preventive women's health care services by providers in the Community Health Plan network, regardless of diagnoses. Family planning services and sexually transmitted disease screening and treatment services provided at family planning facilities such as Planned Parenthood or your local Public Health Department. Immunizations provided by your local Public Health Department. HIV screening and tuberculosis screening and follow-up at your local Public Health Department. For more information about your benefits, contact the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial What Is a Prior Authorization? Community Health Plan must approve some services, supplies, or equipment before the service, supply, or equipment is provided. Community Health Plan must also approve some drugs before you get them. A prior authorization is an approval by Community Health Plan of a procedure or other service on the Prior Authorization List. The Plan decides whether these procedures or services meet the standard of medical necessity. If you get such a procedure or service without a prior authorization from the Plan, the Plan might not pay for it. For more information about medical necessity, see the Community Health Plan website ( Click the Our Plans tab and click Healthy Options. Click the link to How to Find Important Information and then follow the link to the page about Utilization Management. When Do I Need to Get a Prior Authorization? You will need an authorization by Community Health Plan before you get the services listed in the Prior Authorization List. If you get a treatment that is not covered or get a service that requires approval before you get the authorization, the Plan will not pay for it. It is best to talk to your PCP before you get nonemergency services or supplies. Prior Authorization List The drugs, equipment, services, and supplies on the Prior Authorization List must be reviewed for medical necessity and approved by Community Health Plan before you get the drugs, equipment, services, or supplies. Otherwise, Community Health Plan will not pay for them. If a service is not listed, it might not be a Community Health Plan covered benefit. Your Healthy Options Benefits Page 17

18 The Prior Authorization List includes many of the common services you might need. It provides a guideline to which services, drugs, supplies, and equipment require a prior authorization, but it might not include every service and every detail about a service. It also can change as state regulations change, as services available from our providers change, and as medicine itself advances. For more detailed information about a specific service, drug, or equipment: See the "Benefits and Services Covered by Community Health Plan of Washington" list in this booklet. Contact the Community Health Plan customer service team at , Monday Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial To see the most current Prior Authorization List: On the Community Health Plan website ( select the Member Services tab and then select Patient Safety. Click the link to the Prior Authorization List. You can also download a PDF of the list to print and read. If you want a printed Prior Authorization List sent to you, please contact the Community Health Plan customer service team at , Monday Friday 8:00 am 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Your Healthy Options Benefits Page 18

19 HOW TO GET MORE INFORMATION You can learn more about Medical Care Services, about Community Health Plan of Washington, and about how to use your plan. We send you information: We send you printed information when you become a member, annually during the time you are a member, and at other times to make sure you get the most out of your health care. You can request printed information: This packet includes a postcard to order printed information about specific topics or a booklet that includes all of your member information. You can get this information anytime you want it. You can request information in another language or another format: You can also ask us to translate the information into the language you prefer to read. If your vision is impaired or you have difficulty reading, we can read the information to you. To get more information about your plan: The How to Find Important Information sheet enclosed in this package lists information available to you and tells you how to find the information or get a printed copy sent to you. To find a provider, pharmacy, clinic, or hospital, visit the Community Health Plan of Washington website at Click the Providers tab and select the type of search you want. To get a printed report or have someone search for you, contact our customer service team. (Contact information below.) You can also search our formulary (approved drug list) to find out if your prescription is covered. Visit our website, Click the Providers tab and select Formulary Search. To get a printed report or have someone search for you, please contact our customer service team. (Contact information below.) Contact the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Your Healthy Options Benefits Page 19

20 2012 Community Health Plan of Washington HO_002_Benefits_July2012