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Utilization Management (UM) is a process that
helps decide if certain outpatient care services,
inpatient hospital stays or procedures are medically
needed and covered by the plan.
Decisions are only based on what is right for each
member, based on the type of care and service. We
look at standards of care taken from:
•
Medical policies.
•
National clinical guidelines.
•
Your health benefits.
You should know:
•
Employees, consultants or other providers are not
rewarded or offered money or other incentives to
deny care or service.
•
They are not rewarded for supporting decisions
that result in the use of fewer services.
New treatments
and procedures
Helping you get care that
is safe and right for you
When it comes to the latest information
about medical care, we work to review
it quickly. We have teams of health
care experts who review medical,
mental health and drug policies on
an ongoing basis.
We look at a variety of resources, including:
•
Medical journals.
•
Government policies and procedures.
•
Studies that show the effects of the new
technology on long-term health.
•
Doctors and other health care experts.
We update our health policies and even
create new ones to address many new
treatments. Helping you stay healthy is
our No. 1 goal.
Notice of Privacy Practices
We care about your privacy. Our Notice of
Privacy Practices tells you how we keep your
information private. It also tells you what rights
you have to see and manage your information.
To learn about your privacy rights, follow
these steps:
❯
❯
Go to
UniCare.com
.
❯
❯
At the top of the screen, click on
Medicaid
.
❯
❯
In the
Select a State
menu, choose
West
Virginia
. Click the orange
Enter
button.
❯
❯
Choose
Notice of Privacy Practices
.
Your pharmacy benefits program
There are great tools to help you manage
your prescriptions online. And they’re easy to
use. At our site, you can:
•
Find out medicine (drug) costs.
•
Order a drug refill.
•
Check for drug-to-drug interactions, side
effects and major risks.
•
View and search the drug list and changes
(called the Exclusive Specialty Drug List).
The drug list is reviewed and updates are
posted to the website quarterly.
•
Fill your prescription at an in-network
pharmacy. You can get a list of these
pharmacies on our website or by calling
the Member Services number on your
ID card.
•
Find out other information about certain
drugs. Some drugs require that you get an
OK before you can get the prescription.
There also may be step therapy, quantity
limits, an exception, or age or gender limits,
depending on the drug. Or it might be a
drug that’s right for dose optimization.
(That 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.) Different rules
help to make sure drugs are used safely
and correctly.
•
See if a drug has a limit in place. If it does,
it will be noted on the Drug List. The drug
must be approved by your plan first. Please
call us with any questions.
To learn more, go to
UniCare.com
. You may
also ask for a paper copy to be faxed or mailed
to you. Or you can call us at
1-800-782-0095
.
Please remember to check the website for
periodic updates throughout the year.
If you have hearing or speech loss, please
call the TTY line at
1-866-368-1634
.
How do we decide if we’ll cover a
treatment, procedure or hospital stay?
We use our Utilization Management process
•
We do not make decisions about hiring,
promoting or firing these people based on the
idea that they will deny benefits.
To learn more about UM or a case, call us toll-free
from 8 a.m. to 5 p.m. weekdays, except holidays,
at
1-866-655-7423
. If you would like to talk to
someone in a language other than English, ask for
an interpreter in your language. If you have hearing
or speech loss, call the TTY line at
1-866-368-1634
.
If you call at any other time, you can leave a private
message. Our staff will return your call on the next
business day during the hours above. Or you can
ask that someone call you back at a different time.
Any staff members who call you about a UM issue
will give you their name and title and the name of
the company.
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My Health