Physicians Health Choice knows that you have questions regarding your coverage. Here, we’ve compiled a list of frequently asked questions. Can’t find what you’re looking for? Contact Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, and we will be happy to help you.

New Member

• As a new member, when do I get my Member ID card?
• Do I have to use Physicians Health Choice providers?
• How do I transfer my medical records?

Using the Plan & Accessing Services

• How do I file a complaint?
• What should I do if I have an emergency after hours when my Primary Care Physician’s office is closed?
• What if I have a medical emergency when I’m out of town?
• How do I seek reimbursement for services I had to pay for?
• How do I change my Primary Care Physician (PCP)?
• How do I get a duplicate ID card or notify you of my address change?
• What is an Appeal?
• What is a Physician Assistant?
• What is a Quality Assurance/Quality Improvement program?

Part D Prescription Drugs

• I receive Part D Extra Help, also known as Low Income Subsidy (LIS). What is my monthly plan premium?
• I am traveling and need to fill prescriptions. What do I do?
• What is Medication Management Therapy (MTM)?
• Are generic drugs as good as brand name drugs?
• I am a new member of Physicians Health Choice and one of my drugs is not covered by your plan. What can I do?
• What is the policy regarding the Low Income Subsidy if you can’t verify my income?
• My prescription isn’t covered. What can I do?

Once your enrollment form information is verified and entered into our system, you will receive a new member packet that includes your member handbook (also known as the Evidence of Coverage) and other important plan information. Your member ID card will be included in this mailing. You should receive this in about 7-10 business days after we receive your enrollment form. Click here to view a diagram of what you can expect after you enroll with us. Remember, present your Physicians Health Choice ID card when receiving services.

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Yes. Physicians Health Choice is an HMO, which means you need to receive your care from our contracted provider network. This helps to ensure better communication with the physicians treating you. In the event of an emergency, or as your doctor deems necessary, you may need to seek care from a provider that is not contracted with us.

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You may request an authorization form from your primary care physician’s office to have your medical records transferred to him/her.

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How do I file a complaint?

You may contact our Customer Service Department at 1-866-550-4736 (TTY 711)), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, and speak with a Customer Service Specialist who will document and address your complaint. If you prefer to send it in writing, you may mail it to:

Physicians Health Choice
Attn: Grievance Department
P.O. Box 690670
San Antonio TX 78269-0670

To learn more about Appeals please review the Your Rights>Appeals & Grievances section, or refer to your Evidence of Coverage.

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Your Primary Care Physician has an answering service for after-hours calls 7 days a week. The answering service will notify the physician on-call of your urgent or emergency need. The on-call physician will call you back to provide appropriate direction for your health care needs. If necessary, go to the nearest emergency or urgent care facility.

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Go to the nearest emergency or urgent care facility to receive care. Show your Physicians Health Choice member ID card so they can verify your eligibility and benefits.

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Send original receipts and any other documentation to:

Physicians Health Choice
Attn: Claims Department
P.O. Box 29429
San Antonio, TX 78229-9998

Please allow 30 days for processing. You will be reimbursed for covered services less your co-pay.

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Call our Customer Service Department at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, to request a PCP change.

Once Physicians Health Choice changes your PCP, you will receive a new ID card in the mail.

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Call our Customer Service Department at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday.

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An Appeal is a type of complaint you make when you want Physicians Health Choice to reconsider and change a decision about what services or benefits are covered for you; or what Physicians Health Choice paid for a service or benefit. To file an appeal, you may contact Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, or send in writing to:

Physicians Health Choice
Attn: Appeals Department
5800 Northwest Parkway, Suite 125
San Antonio, TX 78249

You may also request an appeal by secure email.

To learn more about Appeals please review the Your Rights>Appeals & Grievances section, or refer to your Evidence of Coverage.

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A Physician Assistant (PA) can provide healthcare services under the supervision of a physician. Physician Assistants must have graduated from an accredited college or university and have an advanced degree as a PA.

What types of services are PAs qualified to perform?

• Take your medical history
• Conduct examinations
• Order and interpret lab and x-rays
• Make diagnosis
• Prescribe medications
• Remove skin tags or moles
• Treat minor injuries by splinting, suturing and casting

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The Utilization Management/Quality Assurance (UM/QA) program is designed to ensure safe and appropriate use of medications covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. The UM/QA program is offered at no additional cost to plan members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D medications. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug-drug interactions,
• Therapeutic duplication,
• Inappropriate or incorrect drug therapy,
• Patient-specific drug contraindications,
• Over-utilization and under-utilization,
• Abuse or misuse.

The UM/QA program ensures that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Clinical interventions

Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient’s drug utilization. Each report identifies individual patients who may require evaluation, the reason for the intervention and therapeutic options for the provider to consider. In addition to the reports, providers may receive educational materials focusing on the medication issue that the intervention addresses.

The following 4 chronic medical conditions have been selected for Medication Therapy Management (MTM) interventions:

• Diabetes
• Dyslipidemia (High Cholesterol)
• Heart Failure
• Hypertension (High Blood Pressure)

Plan members are eligible for the MTM program if they at least 3 of the 4 chronic medical conditions, take 8 or more Medicare Part D-covered medications and are likely to exceed $3,000 in annual costs for covered medications.

Please contact Customer Service at 1-866-550-4736 (TTY: 711) , October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, for more information about the MTM program or other quality assurance policies and procedures.

Please note that these programs may have limited eligibility criteria and are not considered a benefit.

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I receive Part D Extra Help, also known as Low Income Subsidy (LIS). What is my monthly plan premium?

Click here to view the plan premiums.

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Covered Part D drugs are available at most national chain pharmacies or out-of-network pharmacies in special circumstances, including while traveling outside of the Plan’s service area and where there is no network pharmacy.

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We offer a Medication Therapy Management (MTM) program that meets Medicare Modernization Act requirements for MTM programs. The program has been approved by the Centers for Medicare & Medicaid Services (CMS) for program year 2012.

We work with doctors to make sure members get the most medically appropriate, safe and cost-effective medications. The Medicare Modernization Act requires this service, especially for people with complex medication needs. Our drug utilization and MTM programs have two primary goals. One is to ensure appropriate use of medications, and the second is to protect members from the risk of drug side effects and from potentially harmful drug-to-drug combinations. The MTM program targets the following 4 chronic medical conditions:

• Diabetes
• Dyslipidemia (High Cholesterol)
• Heart Failure
• Hypertension (High Blood Pressure)

Plan members are eligible for the MTM if they have at least 3 of the 4 chronic medical conditions, take 8 or more Medicare Part D-covered medications, and are likely to exceed $3,000 in annual costs for covered medications.

Please contact Customer Service at 1-866-550-4736 (TTY: 711), , October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, for more information about the MTM program or other quality assurance policies and procedures.

Please note that these programs may have limited eligibility criteria and are not considered a benefit.

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Did you know that generic prescription drugs can cost up to 80% less than their brand name counterparts? Sound too good to be true? It's not. It's hard to believe that your $100 prescription may be available for $25 — without compromising quality.

When a pharmaceutical company develops a new drug, they invest quite a bit of time and money on research and development, so the FDA (US Food & Drug Administration) grants that company a patent allowing it to be the sole maker and seller of the drug. This can last up to 20 years (this is why not every brand name drug has a generic available). Once the patent expires, other drug manufacturers can apply to the FDA to produce and sell generic versions. Since these makers don't have to bear the cost of the original, name-brand manufacturer, they can charge much less. Competition amongst the generics is another factor that works in your favor as far as cost is concerned. Let's review some common misconceptions regarding generic drugs:

Myth #1: Generic drugs aren't as safe as brand names.
The FDA has the same safety and efficacy guidelines for ALL drugs. "People can use them with total confidence," states Dr. Gary Buehler, Director of the FDA's Office of Generic Drugs.

Myth #2: Generic drugs are less expensive because they are not as effective as brand name drugs and are manufactured in poorer-quality facilities.
Per FDA standards, a generic drug must have the same quality, strength, purity and stability as the brand name. The same standards apply for all drug manufacturers. If the FDA's audit results in a facility that is sub-standard, they will not be permitted to produce drugs. Furthermore, about half of all generics are manufactured in the same facility as their brand counterpart.

Myth #3: Generic drugs have different ingredients than the brand name, hence taking longer to work.
Generic drugs may indeed have a different color, flavor or other inactive ingredient than the brand name. This is due to US trademark laws, which do not allow a generic to look exactly the same as the brand name. The FDA requires generic drugs work as fast and effectively as the brand name. Active ingredients must be the same and have the same medicinal effects.

In short, by choosing generics, you're protecting your pocketbook. Another positive 'side effect' of generic drugs is that it allows Physicians Health Choice to spend money on other important services you need- such as vision and dental coverage, gym memberships and more — at no cost.

Lastly, if you find yourself choosing between your prescription drugs and other necessities, you may qualify for Extra Help from the federal government. We invite you to call our Customer Services department at 1-866-550-4736 (TTY: 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, for more information.

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As a new member in our plan, you may currently be taking drugs that are not on our formulary (drug list) or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 31-day transition supply (unless you have a prescription written for fewer days) of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If the prescription is written for less than 31 days, multiple fills are allowed to provide up to a total of 31 days of a drug. After your first 31-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception. Transition supplies are limited to one fill during the first 90 days you are a member of our plan.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a 93-day supply. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e. in the week before long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is limited, you are required to use the Plan’s exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription for fewer days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

Transition Policy

New Memebers

As a new member in our plan, you may currently be taking drugs that are not on our formulary (drug list) or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 31-day transition supply (unless you have a prescription written for fewer days) of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If the prescription is written for less than 31 days, multiple fills are allowed to provide up to a total of 31 days of a drug. After your first 31-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception. Transition supplies are limited to one fill during the first 90 days you are a member of our plan.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a 93-day supply. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e. in the week before long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or your ability to get your drugs is limited, you are required to use the Plan’s exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription for fewer days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

Continuing Members

As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). You may notice that a formulary medication which you are currently taking is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year.

For coverage requests we receive by December 15, 2011 and approve, the plan will cover the drug as of January 1, 2012. For coverage requests initiated on or after December 16, 2011, normal timeframes for resolution apply: you will receive an answer within 24 hours for urgent requests and 72 hours for all other requests. If your existing medication is subject to new formulary restrictions and you have not discussed switching to an alternative formulary medication or pursued a formulary exception with your doctor, as of January 1, 2012, you may receive a temporary 31-day supply (unless you have a prescription for fewer days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If the prescription is written for less than 31 days, multiple fills are allowed to provide up to a total of 31 days of drugs. After your first 31-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a 93-day supply. If you need a drug that is not on our formulary or your ability to get drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. You may call Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, with questions or for more information.

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