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«Member Handbook UWV-MHB-0003-14 12.14 Dear Member: Welcome to UniCare Health Plan of West Virginia, Inc.! This is your member handbook. Here, you ...»

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Post-stabilization This is the care you get after emergency medical care to keep your condition stable or improve your condition. You have coverage for post-stabilization services (even if your doctor is not part of the UniCare network) if we OK the services. You also have coverage for post-stabilization services if we did not respond to the doctor’s request for an OK within one hour of the request or if your doctor could not contact us because it was after business hours or on a weekend.

What to do when you need urgent care An urgent medical condition is NOT an emergency, BUT needs medical care within 48 hours.

This is not the same as a true emergency. Call your PCP if it is urgent and you need medical help within 48 hours. If you cannot reach your PCP, call our Customer Care Center or our 24-hour nurse help line.

If you are away from home and need urgent care, call one of these right away:

• Your PP at the number listed on your member ID card

• Medall at 1-888-850-1108 (TTY 1-800-368-4424)

• Uniare at 1-800-782-0095 (TTY 1-866-368-1634) Certain drugs on the PDL need an OK from us ahead of time or have limits based on medical necessity.

Copays may apply.

Drugs exempt from copays include:

 Contraception/family planning medications  Diabetic testing supplies, syringes and needles  Three-day emergency supplies of medication A group of doctors and pharmacists checks this list of drugs every three months. These checks help make sure that the drugs on the list are safe and useful. Even though a drug is on the list, your doctor will choose which drug is best for you. If you would like to know if a drug is on our list, please call us or go to unicare.com.

How to fill your prescriptions Most of the time, only generic drugs are covered. When a drug is available as a generic, the brand-name drug is usually not covered. Some drugs (including most brand-name drugs) need an OK from UniCare. In these cases, your doctor must ask for an OK before you get the drug.

Most drugs that are covered by UniCare can be filled for a maximum of a 34-day supply at a time.

Drugs not on the PDL require an OK from us ahead of time. If your doctor thinks you need to take a drug that is not on this list, your doctor will send us a request that tells us why you need the drug. In most cases, UniCare will be able to notify you and your doctor if the medication will be covered or not within 24 hours. If the request is sent on a holiday or a weekend or if we need more information from your doctor, it may take longer.

If you need to start the medication right away, you can ask your pharmacist to give you a 3-day emergency supply of the medication. The pharmacist can call the phone number on the back of your ID card to ask for this 3-day emergency supply for you. We will let your doctor know if we OK your request. If we do not OK your request, we will send you a letter that tells you the medical reasons why.

You can find a list of these pharmacies in our Provider Directory. Or call us and we can help you find a pharmacy in the network near you.

You may only use an out-of-network pharmacy if you have an emergency. If you have to go to an out-of-network pharmacy in an emergency, ask them to call UniCare. If you are out-of-state, have an emergency and need prescriptions, the pharmacy can call the pharmacy provider number on the back of your member ID card to make sure your drugs are covered.

Rx Safe Choice program Some members may require coordination of pharmacy benefits. These members can better manage their health by using the same pharmacy for all their prescriptions. If you need this coordinated care, you will be required to choose one pharmacy to fill your prescriptions. This is called the Rx Safe Choice program. We will send you a letter if we believe you will benefit from this program. You will have 30 days from the date of the letter to request a change to your assigned pharmacy.

If you need help finding a UniCare network pharmacy close to you, call us. Our Customer Care Center can help you find a pharmacy. You also can see a list of network pharmacies at unicare.com/medicaid. If you disagree with our decision to include you in the Rx Safe Choice program, you have the right to file a grievance or appeal. Please see Part 12 How to resolve a problem with UniCare for information about the process that you can use to file a grievance or appeal.

Important things to know when you get your drugs Some drugs may hurt you if you take them at the same time as certain other drugs. To protect your health, we will let your doctor and pharmacist know if we are concerned about the drugs you take.

When you get your prescriptions, let the pharmacist know if you have other health insurance. If you are covered by another health plan, that plan will pay first and UniCare will pay second. The total of the two payments cannot be more than the total amount UniCare allows.

The kinds of drugs UniCare covers

We cover:

 Prenatal vitamins for women up to age 46.

 Multivitamins for members less than 21 years of age.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

UWV-MHB-0003-14 WV MHB ENG 12.14  Prescriptions for behavioral health conditions.Drugs to help you stop smoking. These


- Nicotine patches, gum, lozenges and nasal spray

- Bupropion  Diabetic supplies including:

– Blood glucose monitors (continuous blood glucose monitors are covered under your medical benefit)

- Test strips

- Lancets

- Lancing devices

- Urine glucose testing strips  Flu and pneumonia vaccines for members 19 years of age and older if the vaccine is given by a pharmacist at a pharmacy.

 Shots that you give yourself at home, such as insulin, are covered by your pharmacy benefit.

Most shots that must be given by your doctor in his or her office are covered under your medical benefit, not your pharmacy benefit.

 Prescriptions to replace most lost or stolen drugs, one time per year for each drug. You must make a police report if the stolen medication is a controlled substance. Prescriptions to replace certain lost or stolen medications, such as Suboxone or Sovaldi, are not covered.

If you lose your drugs, call us toll free at 1-800-782-0095 for help. Members with hearing or speech loss can call the TTY line at 1-866-368-1634. We will help you replace eligible lost drugs.

Limits on your prescription drug benefit

We do not cover:

 Drugs used for weight loss or weight gain  Drugs used for cosmetic purposes like wrinkles or hair growth  Over-the-counter (OTC) drugs without a prescription and not on the preferred drug list (PDL) or the OTC list for end-stage renal disease  Drugs used in fertility treatment  Drugs used for erectile dysfunction  Herbal or homeopathic drugs  Nutritional supplements  Drugs for cough and cold symptoms, except those listed on the preferred drug list  Barbiturates, except for phenobarbital and mephobarbital, unless the barbiturate is combined with another active ingredient  Vacation supplies and early refills of drugs  Prescriptions for any drugs that are not medically necessary  Drugs that duplicate a therapy that you are already taking unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

For women:

 Well-woman care, including information about healthy behaviors and the need for regular exams, mammograms and cervical cancer screenings  Family planning can help teach you:

- How to be as healthy as you can before you get pregnant

- How to prevent pregnancy

- How to prevent sexually transmitted infections like HIV/AIDS  Pregnancy and childbirth classes give you knowledge to help you have a healthy pregnancy.

 Our maternity program Taking Care of Baby and Me provides educational materials to help you have a healthy pregnancy. You will also have access to a nurse case manager or care coordinator to assist you with your pregnancy if high risk, and to answer your questions.

The nurse will work closely with you and your provider to make sure you are getting the services and resources you need for a healthy pregnancy. Plus, you get rewards just for going to prenatal visits and your postpartum visit on time. Your baby also may qualify for rewards for completing well child checkups.

For you and your child:

 Well-child care programs to help you keep your child healthy. You can learn about healthy behaviors for your child, the need for regular doctor visits and shots (immunizations)  Parenting tips to learn how to care for your child

For weight loss:

We’ve teamed up with Weight Watchers® to help members who are ready to lose weight. To

be eligible, you must be one of the following:

 18 years of age and older with a body mass index (BMI) greater than 25  10 to 17 years of age and have a:

- BMI in the 85th percentile or above for age and gender

- Parent or guardian’s consent to take part in Weight Watchers

- Doctor’s referral If you want to sign up and attend Weight Watchers at no cost to you, please call our CRC toll free at 1-888-611-9958. This offer is for new Weight Watchers members only.

® WEIGHT WATCHERS is the registered trademark of Weight Watchers International, Inc., and is used under license.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

• A free cellphone. When you sign up for a Safelink ® cellphone through UniCare, you get a free cellphone with up to 250 minutes per month, plus 200 bonus minutes, free unlimited nationwide texting and unlimited calls to the UniCare Customer Care Center.

SafeLink Wireless® is a Lifeline-supported service. Lifeline is a government benefit program.

Only those who qualify may enroll in Lifeline; It can’t be transferred; It is limited to one per household. You may need to show proof of income or that you take part in the program to enroll.

Disease Management UniCare has a Disease Management program. A team of licensed nurses and social workers, called Disease Management case managers, will teach you about your condition and help you learn how to manage your care. Your PCP and our team of case managers will help you with your health care needs.

Disease Management case managers provide support over the phone for members with:

 Diabetes  HIV/AIDS  Behavioral health conditions

- Bipolar disorder

- Major depressive disorder

- Substance use disorder

- Schizophrenia  Heart conditions

- Coronary artery disease

- Congestive heart failure

- High blood pressure unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

Disease Management case managers work with you to set health goals and help make a plan to

reach them. As a member in the program, you will benefit from having a case manager who:

 Listens to you and takes the time to understand your needs.

 Helps you make a care plan to reach your health care goals.

 Gives you the tools, support and community resources that can help you improve your quality of life.

 Gives you health information to help you make better choices.

 Helps coordinate care with your providers.

As a UniCare member enrolled in the Disease Management program, you have certain rights

and responsibilities. You have the right to:

 Have information about Disease Management. This includes:

- Programs

- Services

- Our staff’s education and work experience

- Our contracts with other businesses  Refuse to take part in or disenroll from the program  Know which staff members help with your health care services and who to ask for a change  Have case managers help you make choices with your doctors about your health care  Know about all Disease Management-related treatments. These include anything stated in the clinical guidelines, whether covered or not by UniCare. You have the right to discuss all options with your doctors.

 Have your personal and medical information kept private

- Know who has access to your information

- Know what DMCCU does to keep your information private  Be treated with courtesy and respect  Know our complaint (grievance) process:

- How to file a complaint

- Standards of timely response to complaints

- How to solve issues of quality  Get information you can understand

You have the responsibility to:

 Listen and know the importance of accepting or rejecting health care advice  Provide UniCare with information needed to carry out our services unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

If you have one of these conditions or would like to know more about Disease Management, please call 1-888-830-4300, Monday through Friday from 8:30 a.m. to 5:30 p.m. If you have hearing or speech loss, please call the AT&T Relay Service toll-free at 1-800-855-2880. Ask to speak with a Disease Management case manager.

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