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My Health
Did you know there are standards that limit the amount
of time you have to wait to get care? Te Department of
Managed Health Care requires that as a member enrolled
in our plan, you receive appointments within certain time
frames. You also have access to providers 24 hours a day, 7days
a week. Te goal is to make sure you get needed services in a
timely manner. Below are the most current standards.
New to the plan?
Get an initial health exam
The frst exam with the PCP for you or your child is called
an initial health exam. It’s very important. You should get it
right away. Why? It helps your PCP:
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Learn about you and your health before you get sick.
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Look at past or ongoing health issues.
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Go over the drugs you’re taking to make sure
they’re working.
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Tell you what checkups, shots or tests you need.
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Study your family’s medical history.
Call your PCP for an exam today! If you need help fguring
out how to make that frst health exam appointment, call
us at
1-888-285-7801
. If you have hearing or speech loss,
call the TTY line at
1-888-757-6034
.
Your pharmacy
benefts program
There are tools to help you manage your prescriptions
online. At our website, you can:
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Check for drug interactions, side effects and major risks.
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View and search the drug list (called Preferred Drug List).
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Fill your prescription at an in-network pharmacy. You
can get a list of these pharmacies at our website or
by calling the Customer Care Center number on your
ID card.
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You could have a copay and/or a deductible for each
prescription. Your plan may include benefts with a
deductible and/or copays.
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Some drugs require that you get an OK ahead of time.
There also may be step therapy, quantity limits, age/
gender limits or dose optimization. (This is when you
take a drug more than once a day; sometimes your
doctor can prescribe a higher amount that you only
have to take once a day.) This helps ensure safe,
correct use.
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If a drug has a limit in place, it is noted on the
Preferred Drug List. The drug must be approved by
your plan before flling the prescription. Please call
us with any questions.
For more on our pharmacy benefts and tools, log in
to
anthem.com/ca
. You may also ask for a paper copy
by fax or mail. Or you can call us at
1-888-285-7801
.
If you have hearing or speech loss, please call the TTY
line at
1-888-757-6034
.
Speak to a nurse 24/7
Problems don’t just crop up between 9 a.m. and 5 p.m.
Sometimes you’re miles from the doctor’s offce. Or it’s
late at night when your child gets a high fever. What should
you do?
You can reach a registered nurse – for free – anytime of
the day or night from anywhere in the U.S. Simply call the
24/7 NurseLine at
1-800-224-0336
. Add this number to your
cell phone contacts today. If you have hearing or speech loss,
call the TTY line at
1-800-368-4424
.
Nurses have been carefully trained to help you fgure out the
care you need or what to do next. A nurse on the phone can
help answer your questions like: Should you head to the nearest
emergency room? Or can treatment wait until you get to your PCP?
If you have a true emergency, always call 911 frst or go to the
nearest emergency room right away. A true emergency is a
condition that comes on suddenly and shows severe symptoms.
If it’s not an emergency, call your PCP or the 24/7 NurseLine.
One easy call can help you make the right choice of where to
go and how to get the care you need.
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If the provider or answering service is not
immediately available, an answering machine may
be used to instruct members with emergency health
care needs to call 911 or to go directly to the nearest
emergency room.
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Members also can call the 24/7 NurseLine for
answers about:
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Health concerns.
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Triage and screening.
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Prescription drugs.
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Local health care services.
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Where to go for the right health care services.
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Te waiting time for the visits outlined here may be
lengthened by a provider who needs to refer you to
someone else or by the treating doctor or one giving
triage or screenings.
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Te provider must be acting within the scope of
his/her medical license.
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He or she must note in the right record that a longer
waiting time will not harm your health.
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When a provider or you need to reschedule an ofce
visit, the visit must be rescheduled within a time that
is right for your health care needs. Te doctor must
ensure continuity of care.
As a member, you should know that:
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PCPs are required to be available 24 hours a day by
telephone, or services must be available through an
on-call provider. Tey must have documented triage
and screening services. Triage is a way they fgure
out the priority for caring for patients based on how
urgent the health problem is.
General Visit Scheduling (effective January 18, 2011)
Emergency exams
Immediate access 24 hours
a day, 7 days a week
Urgent exams
Within 24 hours of request
Nonurgent sick exams
Within 48 to 72 hours of
request, as clinically needed
Routine care, nonurgent
(primary care)
Within 10 business days
of request
Nonurgent care with
nonphysician mental
health care providers
Within 10 business days
of request
Nonurgent care with
specialist physicians
Within 15 business days
of request
Nonurgent care for ancillary
services (services for
which charges are made in
addition to routine services)
Within 15 business days
of request
Getting care
when you need it