PROVIDER REFERRAL GUIDE BREVARD COUNTY CHECK OUT OUR WEBSITE!!!

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1 PROVIDER REFERRAL GUIDE BREVARD COUNTY CHECK OUT OUR WEBSITE!!! FHCP Central Referral Department 386 / or 800 / (Ext. 3230) Fax: 386 / or 877 / Manager of Central Referrals and Call Center Services Sue Schack, L.P.N. 386 / or 800 / (Ext. 3230) Central Referrals Clinical Supervisor / Susan Dreggors, L.P.N. 386 / or 800 / (Ext. 3230) Community Relations Coordinator / Katherine Sonn 386 / , (Ext. 3883) or 800 / (Ext. 3883) FHCP Case Management Utilization Review Department 386 / or 866 / Case Management Coordination of Care Department 386 / or 800 / (Ext. 7288) Provider Benefit & Eligibility Questions 386 / or 844 / ************************************************************************************************************************ Indicates pre-authorization needed By FHCP Central Referrals Department. For URGENT requests that require pre-authorization, the requesting provider/staff MUST CALL FHCP Central Referrals at 386 / or 800 / (Ext. 3230) ************************************************************************************************************************ Services that require pre-authorization must have documentation as to the medical necessity. If that documentation is not available, your request may be denied. Please refer to your Provider Referral Guide for assistance in referring your patients for services. 1 3/01/17

2 2 3/01/17 TABLE OF CONTENTS The Table of Contents listed below outlines Florida Health Care Plan s Preferred Participating Providers ALLERGY... 7 AMBULATORY SURGERY CENTERS... 7 ARTERIAL BLOOD GASES (ABG s)... 8 BARIATRIC SURGERY PROGRAM... 8 BIRTH CENTER... 9 BONE DENSITY STUDIES BONE DENSITY STUDIES (continued) BONE SCANS BONE SCANS (continued) BRACES / ORTHOTICS / PROSTHETICS DIABETIC SHOE PROVIDERS CARDIAC CATHETERIZATION CARDIAC MONITORING CARDIAC REHABILITATION CARDIOLOGY CARDIOLOGY (continued) CARDIOLOGY (continued CARDIOLOGY-PEDIATRIC CASE MANAGEMENT COORDINATION OF CARE DEPARTMENT CASE MANAGEMENT COORDINATION OF CARE DEPARTMENT (continued) CASE MANAGEMENT UTILIZATION REVIEW DEPARTMENT CHIROPRACTIC COLOGUARD TESTING COLONOSCOPY / DIAGNOSTIC COLONOSCOPY / SCREENING COMPLEX HOME CARE MANAGEMENT CONTRACEPTION CT SCANS CT SCANS (continued) DENTAL SERVICES - MEDICAL DERMATOLOGY DIABETES EDUCATION... 30

3 DIAGNOSTIC TESTING DIAGNOSTIC TESTING (continued) DIALYSIS SERVICES DISEASE MANAGEMENT PROGRAMS DISEASE MANAGEMENT PROGRAMS (continued) DISEASE MANAGEMENT PROGRAMS (continued) DISEASE MANAGEMENT PROGRAMS (continued) DURABLE MEDICAL EQUIPMENT DURABLE MEDICAL EQUIPMENT (continued) OXYGEN ORDERS DURABLE MEDICAL EQUIPMENT (continued) POV S / ELECTRIC WHEELCHAIR ORDERS EAR, NOSE AND THROAT (ENT) ECHOCARDIOGRAMS EEG TESTING EEG TESTING AMBULATORY ELECTROCARDIOGRAMS (EKG S) EMG TESTING ENDOCRINOLOGY EVENT MONITOR FACILITIES: NOT LISTED IN FHCP DIRECTORIES FLIGHT PHYSICALS GASTROENTEROLOGY GENETIC TESTING BRCA TESTING GERIATRIC MEDICINE GLUCOMETERS GYNECOLOGY AND WELL WOMAN S ASSESSMENTS GYNECOLOGY AND WELL WOMAN S ASSESSMENTS (continued) HAND THERAPY SERVICES HEARING / AUDIOLOGY TESTING SERVICES HEPATITIS C HOLTER MONITOR HOME HEALTH CARE HOME INFUSION PHARMACIES HOSPICE HOSPITAL ADMISSIONS /01/17

4 LTACH ADMISSIONS LONG TERM ACUTE CARE HOSPITALS HOSPITALIST / INTENSIVIST HYPERBARIC OXYGEN THERAPY (HBO) IMMUNIZATIONS INFECTIOUS DISEASES INFECTIOUS DISEASES-PEDIATRICS INFUSION CLINIC INFUSION SERVICES (INFUSION PUMPS FOR CHEMOTHERAPY) INSULIN PUMPS INSULIN PUMPS (continued) INTERPRETER SERVICES INTERPRETER SERVICES (continued) LABORATORY SERVICES-HOME LABORATORY SERVICES ROUTINE AND STAT LABORATORY SERVICES ROUTINE AND STAT (continued) LABORATORY SERVICES STAT GENETIC AND COLOGUARD TESTING LACTATION SERVICES/BREASTFEEDING CLASSES LYMPHEDEMA CLINIC MAMMOGRAMS (DIAGNOSTIC OR SCREENING) MAMMOGRAMS (DIAGNOSTIC OR SCREENING) (continued) MEDICATIONS (REQUIRING PRIOR AUTHORIZATIONS) MRI S MRI S (continued) NEONATAL & PERINATAL HIGH RISK PREGNANCY & INFANT CASE MANAGEMENT NEPHROLOGY NEUROLOGY NON-LISTED PROVIDERS NUTRITIONAL ASSESSMENT AND COUNSELING OBSTETRICS OBSTETRICS (continued) OCULAR PROSTHETICS LAB ONCOLOGY MEDICAL/HEMATOLOGY ONCOLOGY MEDICAL/HEMATOLOGY (continued) ONCOLOGY-RADIATION ONCOLOGY-RADIATION THERAPY OPHTHALMOLOGY /01/17

5 OPHTHALMOLOGY (continued) OPHTHALMOLOGY (continued) OPHTHALMOLOGY- CORNEAL SERVICES OPHTHALMOLOGY RETINAL SERVICES OPHTHALMOLOGY RETINAL SERVICES (continued) OPTOMETRY OPTOMETRY (continued) OPTOMETRY LOW VISION ORAL SLEEP APNEA APPLIANCES OUTPATIENT REHABILITATION FLORIDA HEALTH CARE PLANS OUTPATIENT REHABILITATION LOCATIONS PAIN MEDICINE PATHOLOGY OUT-PATIENT/AMBULATORY PATHOLOGY OUT-PATIENT/AMBULATORY (continued) PEDIATRICS PEDIATRIC-SUB-SPECIALTY PEDIATRIC-SUB-SPECIALTIES NOT LISTED PELVIC HEALTH PROGRAM PERINATAL & NEONATAL HIGH RISK PREGNANCY & INFANT CASE MANAGEMENT PHARMACY-PREFERRED RETAIL PHARMACY PHARMACY-STANDARD RETAIL PHARMACY PHARMACY-STANDARD RETAIL PHARMACY (continued) PHYSICAL MEDICINE AND REHABILITATION SERVICES PODIATRY PODIATRY (continued) PRIMARY CARE PROVIDERS: NOT LISTED IN FHCP DIRECTORIES PSYCHIATRY / BEHAVIORAL HEALTH PSYCHIATRY / BEHAVIORAL HEALTH OUTPATIENT PSYCHIATRY / BEHAVIORAL HEALTH OUTPATIENT (continued) PSYCHIATRY / BEHAVIORAL HEALTH - INPATIENT PSYCHIATRY / BEHAVIORAL HEALTH RESIDENTIAL TREATMENT FACILITY PULMONARY FUNCTION TESTS (PFTs) / SPIROMETRY PULMONARY FUNCTION TESTS (PFTs) with DLCO) PULMONARY REHABILITATION PULMONOLOGY /01/17

6 REPORTABLE DISEASES/CONDITIONS RHEUMATOLOGY SKILLED NURSING FACILITY SLEEP DISORDER PROVIDERS SLEEP DISORDER PROVIDER HOME STUDIES SUBSTANCE ABUSE / DETOXIFICATION & INPATIENT CARE SUBSTANCE ABUSE / RESIDENTIAL SUBSTANCE ABUSE OUTPATIENT CARE SUBSTANCE ABUSE - INTENSIVE OUTPATIENT PROGRAMS SURGERY-CARDIOVASCULAR SURGERY-COLON SURGERY-GENERAL SURGERY-HAND SURGERY-NEURO SURGERY-ORAL SURGERY-ORTHOPAEDICS SURGERY-PLASTIC SURGERY VASCULAR SURGICAL FACILITIES TRANSPLANTS TERTIARY CARE CENTERS ULTRASOUND TESTING ULTRASOUND TESTING (continued) URGENT CARE SERVICES UROGYNECOLOGY UROLOGY VACUUM ASSISTED CLOSURE DEVICES VARICOSE VEIN TREATMENT VNG TESTING WEIGHT MANAGEMENT PROGRAMS WOUND CARE HYPERBARIC OXYGEN THERAPY (HBO) AND VACUUM ASSISTED CLOSURE DEVICES X-RAYS (PLAIN FILMS) X-RAYS (PLAIN FILMS) (continued) /01/17

7 ALLERGY Pavana Beerelli, M.D. # Mark W. Minor, M.D. # All ages Kent N. Leifer, M.D. # All ages Jeannette G. Warner, M.D. # All ages Medical Associates of Brevard LLC 2290 W. Eau Gallie Blvd., Ste. 205, Melbourne, FL / Fax: 321 / Kent N. Leifer, M.D. 375 S. Courtenay Pkwy., Merritt Island, FL / Fax: 321 / Jeannette G. Warner, M.D Malabar Rd., SE., Ste. 1, Palm Bay, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. AMBULATORY SURGERY CENTERS For Ambulatory Surgical Centers (ASC s) please refer to the Surgical Facilities section for In-Network locations and instructions. 7 3/01/17

8 ARTERIAL BLOOD GASES (ABG s) Parrish Medical Center 951 N. Washington Ave., Titusville, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge 110 Longwood Ave., Rockledge, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. BARIATRIC SURGERY PROGRAM East Coast Bariatrics at Halifax Health Wuesthoff Medical Center-Melbourne 201 N. Clyde Morris Blvd., Ste. 100 Daytona Beach, FL / Fax: 386 / N. Wickham Rd., Melbourne, FL / Fax: 321 / All Florida Health Plan Members (FHCP) members that are considering entering the Bariatric Surgery Program must obtain Prior Authorization from the FHCP Central Referral Department before entering the program. INSTRUCTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (977 / ) to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review to see if the patient meets the guidelines and if they have the benefit of Bariatric Surgery. 8 3/01/17

9 BIRTH CENTER Agape Birth & Wellness Center Patients 15 years and older 1346 Mason Ave., Daytona Beach, FL / Fax: 386 / Heart2Heart Birth Center, LLC Patients 16 years and older 1110 Lexinton Green Ln., Sanford, FL / Fax: 407 / The above provider will provide complete outpatient obstetrical services, including vaginal delivery at the Center, to members age 16 years and older for uncomplicated, low-risk pregnancies. INSTRUCTIONS: Member can self-refer to this specialty and will be able to call and schedule an appointment without an order from physician. 9 3/01/17

10 BONE DENSITY STUDIES Atlantis Diagnostics (N) 1344 S. Apollo Blvd., Ste. 102, Melbourne, FL Minton Rd., Ste. 100, Palm Bay, FL / Fax: 321 / / Fax: 321 / Florida Diagnostic Imaging, Inc. (N) 5201 Babcock St. NE, Ste.5 Palm Bay, FL / Fax: 321 / Florida Health Care Plans (N) FHCP Center - Edgewater 386 / Wednesdays only 239 N. Ridgewood Ave., Edgewater, FL Fax: 386 / Parrish Healthcare Center at Port St. John (H) 5005 Port St. John Pkwy., Cocoa, FL / Fax: 321/ Parrish Medical Center (H) 951 N. Washington Ave., Titusville, FL / Fax: 321 / Rockledge MRI & PET Center (N) 1910 Rockledge Blvd., Suite 102 Rockledge, FL / Fax: 321 / University Center Imaging (N) 1800 W. Hibiscus Blvd., Suite 100, Melbourne, FL N. Wickham Road, Suite 100, Melbourne, FL / Fax: 321 / / Viera Diagnostic Center (N) 7000 Spyglass Court, Ste. 260, Viera, FL /01/ Spyglass Court, Ste. 160, Viera, FL N. Wickham Rd., Ste. 101 Melbourne, FL Fax: 321 / / Fax: 321 / / Fax: 321 / / Fax: 321 / Wuesthoff Medical Center-Melbourne (H) 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge (H) 110 Longwood Ave., Rockledge, FL / Fax: 321 / Physician Offices (N) Various locations (H) Outpatient Hospital Department/Facility (N) Outpatient Non-Hospital Facility Out of pocket costs may vary depending on location or benefit plan Additional Bone Density Studies information on the following page:

11 BONE DENSITY STUDIES (continued) Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. FHCP will cover this testing once every 24 months. BONE SCANS Atlantis Diagnostics (N) 1344 S. Apollo Blvd., Ste. 102, Melbourne, FL Minton Rd., Ste. 100, Palm Bay, FL / Fax: 321 / / Fax: 321 / Parrish Healthcare Center at Port St. John (H) 5005 Port St. John Pkwy., Cocoa, FL / Fax: 321 / Parrish Medical Center (H) 951 N. Washington Ave., Titusville, FL / Fax: 321 / Rockledge MRI & PET Center (N) 1910 Rockledge Blvd., Suite 102 Rockledge, FL / Fax: 321 / University Center Imaging (N) 1800 W. Hibiscus Blvd., Suite 100, Melbourne, FL N. Wickham Road, Suite 100, Melbourne, FL / Fax: 321 / / Fax: 321 / Wuesthoff Medical Center Diagnostic Services (H) 2400 N. Courtenay Pkwy., Merritt Island, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne (H) 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge (H) 110 Longwood Ave., Rockledge, FL / Fax: 321 / (H) Outpatient Hospital Department/Facility (N) Outpatient Non-Hospital Facility Out of pocket costs may vary depending on location or benefit plan Additional Bone Scan information on the following page: 11 3/01/17

12 BONE SCANS (continued) Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. BRACES / ORTHOTICS / PROSTHETICS Brevard Prosthetics & Orthotics 966 US Hwy. 1, Rockledge, FL S. Valentine St., Melbourne, FL S. Washington Ave., Ste. D, Titusville, FL / Fax: 321 / / Fax: 321 / / Fax: 321 / Hanger Prosthetics & Orthotics, Inc. 129 W. Hibiscus Blvd., Suite N., Melbourne, FL / Fax: 321 / Orthotic & Prosthetics Center of Melbourne 47 W. New Haven Ave., Ste. 102 Melbourne, FL / Fax: 321 / INSTRUCTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient. 12 3/01/17

13 DIABETIC SHOE PROVIDERS Atlantic Foot & Ankle Associates All ages Certified Diabetic & Medical Services, Inc. Atlantic Foot & Ankle Associates 1404 S. Ridgewood Ave., Edgewater, FL / Fax: 386 / Certified Diabetic & Medical Services, Inc. 190 Fortenberry Rd., Suite 102, Merritt Island, FL / Fax: 321 / PODIATRISTS WILL MEASURE AND ORDER THE SHOES INSTRUCTIONS: Diabetic shoes, inserts and/or modifications to the shoes are covered if the following criteria are met: The patient has diabetes mellitus (ICD-10-CM diagnosis codes Type 1 E10.10 E10.9 Type 2 E11.00 E11.9); and The patient has one or more of the following conditions: Previous amputation of the other foot, or part of either foot, or History of previous foot ulceration of either foot, or History of pre-ulcerative calluses of either foot, or Peripheral neuropathy with evidence of callus formation of either foot, or Foot deformity of either foot, or Poor circulation in either foot FHCP will follow Medicare guidelines for this service. In one year, the patient is eligible for 1 pair of off the shelf diabetic shoes and 3 pairs of custom molded inserts or 1 pair of custom molded shoes with 2 pairs of replacement insoles /01/17

14 CARDIAC CATHETERIZATION Parrish Medical Center 951 N. Washington Ave., Titusville, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge 110 Longwood Ave., Rockledge, FL / Fax: 321 / INSTRUCTIONS: The Cardiologist should schedule the procedure with the hospital, make arrangements for pre-op as needed and notify the member. The requesting Cardiologist should then complete the FHCP Surgical & Special Procedure Form. Fax the form to the FHCP s Central Referrals at the Holly Hill facility 877 / The Referral Department will review the request. The Cardiologist will be notified only if the procedure is not approved. CARDIAC MONITORING irhythm Technologies, Inc. # Townsend St., Ste. 380, San Francisco, CA / Fax: 1/ 888 / irhythm Technologies, Inc. provide a long term continuous ambulatory cardiac monitoring device (Zio Patch) to FHCP members to record and store elect electrocardiogram (ECG) data. Prior authorization from the FHCP Central Referral Department is not required. Participating providers can contact the company directly at the above telephone number. The medical device shall be affixed to the FHCP member at the Participating Provider s office and the member shall wear the device for up to fourteen (14) days as medically necessary. Interpretation and reporting of the ECG data captured by the supplier s medical device will be the responsibility of the ordering Participating Provider. 14 3/01/17

15 CARDIAC REHABILITATION Parrish Medical Center 951 N. Washington Ave., Titusville, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge 110 Longwood Ave., Rockledge, FL / Fax: 321 / INSTRUCTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient Indicate what phase of the program is being requested. 15 3/01/17

16 CARDIOLOGY Joseph Asch, M.D. # Patients 16 years and older Muhammad Aslam, M.D. # Shashin R. Desai, M.D. # Rakesh N. Patel, M.D. # Gopal Gadodia, M.D. # Hany H. Guirgis, M.D. # Hong S. Jeong, M.D. #10U633 Nancy J. Johnson, M.D. # Stephen Watts, M.D. # Joel D. Greenberg, M.D., P.A S. Hopkins Ave., Ste. 103, Titusville, FL / Heart Care PL 1091 Port Malabar Blvd., Ste. A, Palm Bay, FL S. Wickham Rd., West Melbourne, FL Fax: 321 / / Fax: 321 / N. Wickham Rd., Ste. 132 B, Melbourne, FL Medical Associates of Brevard, L.L.C W. Eau Gallie Blvd., Ste. 200, Melbourne, FL / Fax: 321 / Prestige Cardiology Consultants, L.L.C Spyglass Hill Rd., Ste. 105, Melbourne, FL / Fax: 321 / Viera Heart and Vascular Clinic, L.L.C Spyglass Hill Rd., Ste. 105, Melbourne, FL / Fax: 321 / Heart Rhythm Associates 119 Longwood Ave., Rockledge, FL / Fax: 321 / Information on Zoll Life Vests can be found under Durable Medical Equipment Additional Cardiology information on the following page 16 3/01/17

17 CARDIOLOGY (continued) Walter G. Johnson, M.D. # Eugene S. Killeavy, M.D. # Donald P. Messersmith, M.D. # Srinivas Prasad, M.D. #00W928 Kiran R. Modi, M.D. # Patients 14 years and older Naresh V. Mody, M.D. # Biju T. Mathews, M.D. # Nathan Valin, M.D. # Behzad Oskouei # Rao Ravi, M.D. #10AJ69 Guilermo Sanabria, M.D. # David P. Sims, M.D. # James Zavitsanos, M.D. #10B112 Ravindran Palaniyandi, M.D. # Brevard Cardiology Group 150 N. Sykes Creek Pkwy., Ste. 300, Merritt Island, FL Spyglass Hill Rd., Ste. 102, Viera, FL / Fax: 321 / US HWY 1, Ste. 200, Port St. John, FL Kiran Modi, M.D. 500 N. Washington Ave., Ste.106, Titusville, FL / Fax: 321 / Florida Cardiovascular Association, P.A. 605 N. Washington Ave., Ste. 100, Titusville, FL / Fax: 321 / Heart Care Centers of Florida 3822 S. Washington Ave., Titusville, FL Palmetto St. New Smyrna Beach, FL Sanabria & Sims, MDs 1004 Beverly Dr., Ste. C, Rockledge, FL / Fax: 321 / / Fax: 386 / / Fax: 321 / S. Harbor City Blvd., Ste. 200, Melbourne, FL Osler Medical Group 2222 S. Harbor City Blvd., Ste. 440, Melbourne, FL / Space Coast Cardiology Consultants, PA 7139 North Hwy. 1 Port St. John, FL Spyglass Hill Rd., Viera, FL Fax: 321 / / Fax: 321 / (All offices use same phone/fax) Information on Zoll Life Vests can be found under Durable Medical Equipment Additional Cardiology information on the following page 17 3/01/17

18 CARDIOLOGY (continued) Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. Information on Zoll Life Vests can be found under Durable Medical Equipment CARDIOLOGY-PEDIATRIC Parrish Medical Center Emergency Dept. Pediatric Cardiology services will be available through Nemour s Telemedicine services in the Parrish Medical Center Emergency Dept. Either on an emergency or by appointment basis. 951 N. Washington Ave., Titusville, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. The Parrish Medical Center Emergency Department will facilitate patient needs. 18 3/01/17

19 CASE MANAGEMENT COORDINATION OF CARE DEPARTMENT Florida Health Care Plans Case Management Coordination of Care Program is designed to address the needs of all members helping to navigate the health care system. The program is voluntary and the member has the right to decline or discontinue participation. Members are engaged telephonically and face-to-face. Criteria for consideration may include members with acute or chronic diseases i.e., asthma, coronary artery disease (CAD), congestive heart failure (CHF), stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), diabetes, depression, transplants, or major trauma. Members may need coordination of care to assistance with issues involving home safety, life planning, end of life issues, self-management of health conditions, educational and community resources. Members are identified as potential candidates for coordination of care by using the following data sources: On a monthly basis, the FHCP Clinical Measurement Analysis and Reporting department (CMAR) develops reports for review by CM Coordination of Care Department: Claims data - three or more emergency department visits in a three month period of time Pharmacy data - 16 or greater medications (in a month) Data supplied by practitioners - identification of members experiencing late effects of stroke via electronic health record (EHR) Laboratory data - i.e. elevated HgbA1c or LDL-Cholesterol. 2. Case management staff reviews other data sources to identify potential candidates for case management: Hospital discharge data - length of stay greater than 14 days Data collected through the UM process - all hospital readmissions Data supplied by member or caregiver - based on Health Risk Assessment (HRA) quality of life responses (QOL) Please submit The CM Coordination of Care Referral form as located in the Provider Handbook or at to the CM Coordination of Care Department: Telephone Contact: (386) , Toll Free (800) Fax: (386) Website: cmanagement@fhcp.com Internal: E.H.R. Task Additional Case Management Coordination of Care information on the following page 19 3/01/17

20 CASE MANAGEMENT COORDINATION OF CARE DEPARTMENT (continued) Referrals to Community Resource Coordinators Referrals to Community Resource Coordinators (CRC) may be initiated when a member is experiencing psychosocial barriers that impacts health or healthcare delivery that is social or financial in nature. The Community Resource Coordinators will complete individualized assessments and connect members with appropriate existing resources offered within their communities. Services provided by Community Resource Coordinators do not replace discharge planning provided to members in the hospital, skilled nursing facilities, or any services already being provided to members receiving home health care. A referral to the Community Resource Coordinators is not a substitute for urgent evaluation or intervention by their healthcare providers. Please submit The Community Resource Coordination Referral form as located in the Provider Handbook, to the CM Coordination of Care Department: Telephone Contact: (386) , Toll Free (800) Fax: (386) Website: cmanagement@fhcp.com Internal: E.H.R. Task. 20 3/01/17

21 CASE MANAGEMENT UTILIZATION REVIEW DEPARTMENT The FHCP Case Management Utilization Review Department is a multi-faceted case management program designed to monitor, evaluate, assist physicians, members, providers in the care of FHCP members that are in an acute hospital, Skilled Nursing Home, Home Health Care or Long term acute care facility. Office Coordinator Screens incoming calls and coordinates departmental needs Admissions Coordinator Manages authorizations for members admitted to hospitals Data Coordinator Assists both office and admission coordinators, maintains forms, correspondence and manage reporting data as well as authorization management for SNF and HHC Case Management Nurses RN s that review inpatient clinical information for appropriateness of admission and coordinates care upon discharge to ensure that member s needs are met, both locally and out of area. These functions involve physicians, facility Case Mangers/Discharge planners, FHCP administration, FHCP Case Management team and other providers as needed. HHC Coordinator RN that reviews and monitors related clinical information as pertinent to Skilled HHC needs with providers as well as contacting members to assist with potential continued care needs. Assist Triage RN as needed. Skilled Nursing Facility (SNF) Coordinator RN s that coordinate s care and completes on site reviews during a members confinement to a SNF. They work closely with the SNF physicians, facility nursing, therapy, discharge planning staff. Discharge Coordinators - RN s and clerical staff that contact members post discharge from acute hospital for evaluation. This call includes discharge needs in place, appointments in place, medication reconciliation; members are also screened for placement into the short term complex care or referred to the Complex Care Program. To access the FHCP Case Management Department, please call or fax /01/17

22 CHIROPRACTIC Steven L. Smith, D.C. # All ages Joshua C. Flinn, D.C. # Alison M. Nida, D.C. # All ages Kevin G. Fogarty, D.C. # All ages Janaina C. Strater, D.C. #10N885 Joseph J. Strater, D.C. #10F388 Patients newborn and older Timothy Steflik, D.C. #10V838 All ages Bradley G. Watt, D.C. # Britaney M. Watt, D.C. # All ages Paul M. Lombardi, D.C. # All ages Active Spine Center, LLC Garden St. Titusville, FL Fax: 321 / Flinn Chiropractic 950 N. Courtenay Pkwy., Ste 1, Merritt Island, FL / Fax: 321 / Barton Blvd., Rockledge, FL / Fax: 321 / Strater Family Chiropractic 309 N. Orlando Ave., Cocoa Beach, FL / Fax: 321 / Coastal Chiropractic Clinic 315 N. Ridgewood Ave., Ste. 5, Edgewater, FL / Fax: 386 / Watt Family Chiropractic LLC 2255 N. Wickham Rd., Ste. 109, Melbourne, FL / Fax: 321 / Cocoa Chiropractic Center 111 N. Fiske Blvd., Cocoa, FL / Fax: 321 / INSTRUCTIONS: Member can self-refer to this specialty and will be able to call and schedule an appointment without an order from a physician. COLOGUARD TESTING INSTRUCTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax ( ), to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review the request and notify you of their decision. 22 3/01/17

23 COLONOSCOPY / DIAGNOSTIC Ammar Hemaidan, M.D. # Beatrice Bratu, M.D. # Issam Nasr, M.D. #10S757 Saud Suleiman, M.D. # Hassan Zulfiqar, M.D. # Ammar Hemaidan, M.D. # Peter Koretsky, M.D. #10M632 Non-Medicare Members Adwait Jathal, M.D. # John Turse, M.D. # David Schaefer, M.D. # Jain Jun Chen, M.D. # William Rylander, M.D. # Advanced Gastroenterology Healthcare Center FHCP Center - Edgewater 239 N. Ridgewood Avenue, Suite 3, Edgewater, FL / Fax: 386 / All appointment scheduling will be through the Port Orange office Advanced Gastroenterology of Brevard 825 Century Medical Drive, Ste. B, Titusville, FL / Fax: 321 / Peter Koretsky, M.D Pineda Plaza Way, Ste. 115, Melbourne, FL / Fax: 321 / Medical Associates of Brevard, LLC 200 Michigan Ave., Melbourne, FL / Fax: 321 / Osler Medical Group 240 N. Wickham Rd., Ste. 309 Melbourne, FL / Fax: 321 / William Rylander, M.D., P.A. 407 S. Washington Ave., Ste. 1 Titusville, FL / Fax: 321 / INSTRUCTIONS: The GI provider should schedule the procedure, make arrangements for pre-op as needed and notify the member. The requesting GI provider should then complete the FHCP Surgical & Special Procedure Form. Fax the form to the FHCP s Central Referrals at the Holly Hill facility 877 / The Referral Department will review the request. The GI provider will be notified only if the procedure is not approved. 23 3/01/17

24 COLONOSCOPY / SCREENING Ammar Hemaidan, M.D. # Beatrice Bratu, M.D. # Issam Nasr, M.D. #10S757 Saud Suleiman, M.D. # Hassan Zulfiqar, M.D. # Ammar Hemaidan, M.D. # Peter Koretsky, M.D. #10M632 Non-Medicare Members Adwait Jathal, M.D. # John Turse, M.D. # David Schaefer, M.D. # Jain Jun Chen, M.D. # William Rylander, M.D. # Advanced Gastroenterology Healthcare Center FHCP Center - Edgewater 239 N. Ridgewood Avenue, Suite 3, Edgewater, FL / Fax: 386 / All appointment scheduling will be through the Port Orange office Advanced Gastroenterology of Brevard 825 Century Medical Drive, Ste. B, Titusville, FL / Fax: 321 / Peter Koretsky, M.D Pineda Plaza Way, Ste. 115, Melbourne, FL / Fax: 321 / Medical Associates of Brevard, LLC 200 Michigan Ave., Melbourne, FL / Fax: 321 / Osler Medical Group 240 N. Wickham Rd., Ste. 309 Melbourne, FL / Fax: 321 / William Rylander, M.D., P.A. 407 S. Washington Ave., Ste. 1 Titusville, FL / Fax: 321 / INSTRUCTIONS: Member can self-refer to this specialty and will be able to call and schedule an appointment without an order from a physician. Cologuard Testing instructions is listed under Cologuard Testing. 24 3/01/17

25 COMPLEX HOME CARE MANAGEMENT Elizabeth Galfo, M.D. # St. Francis Pathways to Healthcare 1250-B Grumman Place Titusville, FL / Fax: 321 / Referrals to St. Francis Pathways should be considered for FHCP patients with complex medical, psychological and/or social needs requiring focused intervention and assistance in order to remain at home, access care, and facilitate compliance with care recommendations. Close coordination and communication with the patient, physician and family are maintained. INSTRUCTIONS: FHCP encourages and supports direct referrals to Complex Home Care Management by Physicians, Hospitals, Pharmacists, Behavioral Health Professionals, FHCP Members, and Member families. In addition, Coordination of Care, Utilization Review, and Interdisciplinary Care Teams will identify and refer members. To refer a FHCP member, please call St. Francis Pathways to Healthcare at or fax your order to CONTRACEPTION A list of FHCP covered oral contraceptives can be found on the FHCP website at Please check the correct formulary. All other types of contraception benefits can be verified with the FHCP Provider Benefit & Eligibility Department at 386 / or 844 / /01/17

26 CT SCANS Atlantis Diagnostics (N) 1344 S. Apollo Blvd., Ste. 102, Melbourne, FL Minton Rd., Ste. 100, Palm Bay, FL / Fax: 321 / / Fax: 321 / Florida Diagnostic Imaging, Inc. (N) 5201 Babcock St. NE, Ste. 5 Palm Bay, FL / Fax: 321 / NSI Melbourne (N) 2222 S. Harbor City Blvd., Ste. 520, Melbourne, FL / Fax: 321 / NSI Merritt Island (N) 255 N. Sykes Creek Pkwy., Merritt Island, FL / Fax: 321 / Parrish Healthcare Center at Port St. John (H) 5005 Port St. John Pkwy., Cocoa, FL / Fax: 321 / Parrish Medical Center (H) 951 N. Washington Ave., Titusville, FL / Fax: 321 / Rockledge MRI & PET Center (N) 1910 Rockledge Blvd., Suite 102 Rockledge, FL / Fax: 321 / University Center Imaging (N) 1800 W. Hibiscus Blvd., Suite 100, Melbourne, FL N. Wickham Road, Suite 100, Melbourne, FL / Fax: 321 / / Fax: 321 / Viera Diagnostic Center (N) 7000 Spyglass Court, Ste. 260, Viera, FL (H) Outpatient Hospital Department/Facility (N) Outpatient Non-Hospital Facility Out of pocket costs may vary depending on location or benefit plan Additional CT Scan information on the following page 7000 Spyglass Court, Ste. 160, Viera, FL N. Wickham Rd., Ste.101 Melbourne, FL EXCEPTIONS NOTED ON THE FOLLOWING PAGE 321 / Fax: 321 / / Fax: 321 / / Fax: 321 / /01/17

27 CT SCANS (continued) Wuesthoff Medical Center Diagnostic Services (H) 2400 N. Courtenay Pkwy., Merritt Island, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne (H) 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge (H) 110 Longwood Ave., Rockledge, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. See specific instructions in other sections for: Ultrasounds, X-Rays, Mammograms, Event Monitors, Holtor Monitors, EMG s, EKG s, ABG s, PFT s and Echocardiograms. The following items are exceptions to the above and will require Prior Authorization from the FHCP Referral Department. The exceptions to the above are: Breast MRI s Sestamibi Scan (Endocrinologists and Cardiologists can order with no prior authorization) Stereotactic Breast Biopsy Ultrasound Guided Needle Breast Biopsy CT Colonography (Virtual Colonoscopy) Pill Cam Genetic Testing Hida Scans PET SCAN (PCP s ordering PET SCANS must have prior authorization) Knee MRI s (PCP s ordering Knee MRI s must have prior authorization) INSTRUCTIONS FOR EXCEPTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient. 27 3/01/17

28 DENTAL SERVICES - MEDICAL Oral Sleep Apnea Appliances - Please complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Central Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient. Patient must have a Sleep Apnea evaluation with Sleep Studies prior to submitting your request. TMJ services and Medical Dental Services - Please complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Central Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient. 28 3/01/17

29 DERMATOLOGY Richard C. Kirkpatrick, M.D. #10B303 Andrew G. Miner, M.D. # Mario J. Sequeira, M.D. # All ages Rodolfo Chirinos, M.D. # Michael Spicer, M.D. # All ages Brevard Skin and Cancer Centers 1286 Florida Ave., S., Rockledge, FL Hopkins Ave. S., Titusville, FL Spyglass Hill Rd., Ste. 103, Viera, FL Brevard Medical Dermatology, P.A Spyglass Hill Road, Melbourne, FL Century Medical Dr., Ste. B, Titusville, FL / Fax: 321/ / Fax: 321/ / Fax: 321/ / Fax: 321 / / Fax: 321 / Frank Lee, M.D. # Betsy Leveritt, D.O. # Ruben A Moreno, M.D. # years and older Sumeet Thareja, M.D. # All ages accepted Stacia Poole, M.D. # years and older Florida Dermatology Associates, Inc. 80 Woodland Ave., Cocoa Beach, FL Minton Rd., Ste. 5, Palm Bay, FL North US Hwy 1, Cocoa, FL N. Washington Ave., Ste. 109 Titusville, FL N. Wickham Rd., Ste. 118 Melbourne, FL / Fax: 321 / / Fax: 321 / / Fax: 321 / / Fax: 321 / / Fax: 321 / Indigo Dermatology, LLC 675 S. Babcock St., Melbourne, FL / Fax: 321 / Stacia Poole, M.D., LLC 930 S. Harbor City Blvd., Ste. 101, Melbourne, FL / Fax: 321 / INSTRUCTIONS: Member can self-refer to this specialty and will be able to call and schedule an appointment without an order from a physician. 29 3/01/17

30 DIABETES EDUCATION Peggy McLaughlin, RN, BSN, CDE Tammy Bigos, RN, BSN, CDE Amanda Sprague, RD, LDN, CDE Susan Coleman, MS, RD, LDN, CDE All ages Diabetes Education and Nutrition Services Parrish Medical Office 7075 Highway US-1, Suite 300 Port St. John, FL Classes available at various locations or on an individual basis depending on the need. 321 / Fax: 321 / Parrish Medical Center Diabetes Education Program 7075 Highway US 1, Ste. 300, Port St. John, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. ALL DIABETIC EDUCATION REQUESTS ARE TO BE SENT TO THE PARRISH MEDICAL CENTER GROUP INSTRUCTIONS: The requesting provider will complete a referral for Diabetes Self-Management Training (diabetes education) and fax it to the department. PMC staff will call the patient to schedule appointments after the referral has been received. Appointments can also be made by the physician s office or the member after the referral has been received. The department will advise you of their scheduling protocol. Always document ICD-10 code for service requested. Services provided include, but are not limited to: 10 Hour Diabetes Self-Management Program Diabetes Pre-diabetes Gestational diabetes Insulin starts Insulin pump management 1:1 individual instruction for patients with special needs/circumstances The DIABETES EDUCATION & NUTRITION SERVICES form needed for the above services is available at fhcp.com Providers and then Forms 30 3/01/17

31 DIAGNOSTIC TESTING Atlantis Diagnostics (N) 1344 S. Apollo Blvd., Ste. 102, Melbourne, FL Minton Rd., Ste. 100, Palm Bay, FL / Fax: 321 / / Fax: 321 / Florida Diagnostic Imaging, Inc. (N) 5201 Babcock St. NE, Ste.5 Palm Bay, FL / Fax: 321 / NSI Melbourne (N) 2222 S. Harbor City Blvd., Ste. 520, Melbourne, FL / Fax: 321 / NSI Merritt Island (N) 255 N. Sykes Creek Pkwy., Merritt Island, FL / Fax: 321 / Parrish Medical Group Diagnostic Office (N) 3045 Columbia Blvd., Ste. 108A Titusville, FL / Fax: 321 / Parrish Healthcare Center at Port St. John (H) 5005 Port St. John Pkwy., Cocoa, FL / Fax: 321 / Parrish Medical Center (H) 951 N. Washington Ave., Titusville, FL / Fax: 321 / Rockledge MRI & PET Center (N) 1910 Rockledge Blvd., Suite 102 Rockledge, FL / Fax: 321 / University Center Imaging (N) 1800 W. Hibiscus Blvd., Suite 100, Melbourne, FL N. Wickham Road, Suite 100, Melbourne, FL / Fax: 321 / / Fax: 321 / Viera Diagnostic Center (N) 7000 Spyglass Court, Ste. 260, Viera, FL /01/ Spyglass Court, Ste. 160, Viera, FL N. Wickham Rd., Ste. 101 Melbourne, FL (H) Outpatient Hospital Department/Facility (N) Outpatient Non-Hospital Facility Out of pocket costs may vary depending on location or benefit plan EXCEPTIONS NOTED ON THE FOLLOWING PAGE Additional Diagnostic Testing information on the following page. 321 / Fax: 321 / / Fax: 321 / / Fax: 321 /

32 DIAGNOSTIC TESTING (continued) Wuesthoff Medical Center Diagnostic Services (H) 2400 N. Courtenay Pkwy., Merritt Island, FL / Fax: 321 / Wuesthoff Medical Center-Melbourne (H) 250 N. Wickham Rd., Melbourne, FL / Fax: 321 / Wuesthoff Medical Center-Rockledge (H) 110 Longwood Ave., Rockledge, FL / Fax: 321 / Prior authorization from the FHCP Central Referrals is not needed. The requesting provider will send an order to the specialist. Appointments can be made by the physician s office or the member can call after the order has been received by the specialty office. The specialty office will advise you of their scheduling protocol. See specific instructions in other sections for: Ultrasounds, X-Rays, Mammograms, Event Monitors, Holtor Monitors, EMG s, EKG s, ABG s, PFT s and Echocardiograms. The following items are exceptions to the above and will require Prior Authorization from the FHCP Referral Department. The exceptions to the above are: Breast MRI s Sestamibi Scan (Endocrinologists and Cardiologists can order with no prior authorization) Stereotactic Breast Biopsy Ultrasound Guided Needle Breast Biopsy CT Colonography (Virtual Colonoscopy) Pill Cam Genetic Testing Hida Scans PET SCAN (PCP s ordering PET SCANS must have prior authorization) Knee MRI s (PCP s ordering Knee MRI s must have prior authorization) INSTRUCTIONS FOR EXCEPTIONS: Complete the FHCP Referral Form. Attach pertinent documentation to substantiate the request and forward by fax (877 / ) to FHCP s Central Referrals at the Holly Hill facility. The Referral Department will review the request and notify you of their decision. If approved, FHCP will schedule the member s appointment and also confirm the appointment with the patient. 32 3/01/17

33 DIALYSIS SERVICES DVA Renal Healthcare, Inc. (Davita) 2235 S. Babcock St., Melbourne, FL / Fax: 321 / North Melbourne Dialysis ALL ADMISSIONS are handled through the 14 Suntree PL., Ste. 102 Melbourne, FL / Fax : 321 / downtown Orlando Central Florida Kidney location. Please contact Jaenea or Jayne at 407 / Ext Palm Bay Kidney Center ALL ADMISSIONS are handled through the 220 Medplex Pkwy, NE Palm Bay, FL / Fax: 321 / downtown Orlando Central Florida Kidney location. Please contact Jaenea or Jayne at 407 / Ext Parrish Medical Dialysis Center 830 Medical Center Dr., Ste. C, Titusville, FL / Fax : 321 / INSTRUCTIONS: The Nephrologists office should call the dialysis center directly to schedule an appointment. Pre-authorization from the Referral Department is not needed and a FHCP Referral form does not need to be completed. 33 3/01/17

34 DISEASE MANAGEMENT PROGRAMS Florida Health Care Plans Health and Disease Management Programs Below is a summary of programs available to FHCP, members. Members can participate in programs by calling the number listed on the program or request in writing by completing the FHCP DM Program Enrollment Form located at FHCP facilities and online at or by calling (386) ext Hearing impaired may call TRS Relay 711. Members are not limited in the number of programs they can participate in. Asthma This is a free program that provides education to assist Members in managing symptoms and following your doctor s treatment plan. Some Members may receive a phone call from a nurse for health coaching. Additionally, free asthma tool kits (handouts) are available. Request a tool kit by calling the Disease Management Department at (386) ext. 7242, Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay 711 for more information. Case Management Program This free program is available to all FHCP members, this program offers telephonic management and care coordination. Members must meet screening criteria; such as multiple health problems, medically needy, polypharmacy, or service utilization issues. Any Provider or staff may refer Members to the program. Physician offices or members may call the Member Services Department at (386) or , hearing impaired can call TRS Relay 711, Monday through Friday, 8:00 a.m. to 8:00 p.m. to request a referral form. Chronic Obstructive Pulmonary Disease (COPD) This free program provides education to Members to effectively manage their COPD condition. Education materials may be mailed to your home and include the basics for good self-management. Members meeting certain criteria may receive a phone call from a nurse for health coaching and participation in a prevention program aimed at early intervention when symptoms are worsening. For more information call the Disease Management Department at (386) ext. 7242, Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay /01/17

35 DISEASE MANAGEMENT PROGRAMS (continued) Controlling High Blood Pressure (Hypertension) This program includes a free tool kit that helps you to increase your awareness of the risks related to high blood pressure. The tool kit includes information on how to measure your blood pressure, the importance of routinely taking your medications, diet tips, exercise, and other selfmanagement tools. Included is a discount coupon to purchase a home blood pressure monitor at our FHCP pharmacies. Request a tool kit by calling the Disease Management Department at (386) ext. 7242, Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay 711. FHCP also offers a two hour hypertension self- management class taught by Registered Dieticians. This free class focuses on the DASH diet, and low sodium education. Pre-registration is required. Classes and appointments are offered in various facilities. For more information or to register call (386) or , Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay 711 for more information or to register. Depression Program This free program is for Members ages 18 and above who have a diagnosis of depression. Education materials cover the basics of depression selfmanagement, taking prescribed medications, and methods of coping. Some Members who have a new diagnosis of depression, or are prescribed new antidepressant medication, may receive a phone call for health coaching. Members who would like to see a behavioral health counselor, should call your primary care physician or Member Services department at (386) or To request to participate in this program, please call the Disease Management Department at (386) ext. 7242, Monday through Friday, from 8:00 a.m.-5:00 p.m. Or call the hearing impaired may call TRS Relay 711. Diabetes This is a FHCP free program is for members who have diabetes. A diabetes toolkit which covers the basics of diabetes self-management is available upon request. In addition some members with diabetes who may not be at goal for HbA1c rates may receive a call for health coaching. Request educational information by calling the Disease Management Department at (386) ext. 7242, Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay 711. FHCP in conjunction with the Parrish Medical Center Diabetes Education and Nutrition Services, offers a variety of classes to include a comprehensive Diabetes Education Program, and Pre-Diabetes self-management class. Classes are approved by the American Diabetes Association. The class is taught by Certified Diabetes Educators and Dieticians. The goal of this program is to provide tools, skills, and techniques for self-management. For more information or to register call (321) , Monday through Friday, from 8:00 a.m.-5:00 p.m. The hearing impaired may call TRS Relay 711. Call Member Services department at (386) or for copay or plan information. 35 3/01/17