MARIPOSA COUNTY HUMAN SERVICES PROVIDER LIST

Size: px
Start display at page:

Download "MARIPOSA COUNTY HUMAN SERVICES PROVIDER LIST"

Transcription

1 Behavioral Health and Recovery Services 5362 Lemee Lane (209) MARIPOSA COUNTY HUMAN SERVICES PROVIDER LIST Services Provided: Adult and Children ADA Compliant Facility: Yes LICENSE CA STAFF NAME PROVIDER TYPE LICENSE # NPI # COMPETENCY TRAINED Amy Olson Clinician AMFT Yes Kadi Cruickshanks Clinician APCC Yes Kyle Jenkins Clinician AMFT Yes Pamela Short Clinician ASW Yes Rachel Gren Clinician AMFT Yes Wendy Jaskowiak Clinician AMFT Yes Jonathan Harry Psychiatrist MD Yes Glenn Ikawa Psychiatrist MD Yes Hoyle Leigh Psychiatrist MD Yes Harjot Singh Psychiatrist MD Yes Charlene Martin Nurse LVN Yes Valerie Trujillo Nurse LVN Yes COMMUNITY CONTRACT PROVIDERS Quest Community Counseling Services 5037 Bullion Street (209) Services Provided: Adult Only ADA Compliant Facility: No LICENSE CA STAFF NAME PROVIDER TYPE LICENSE # NPI# COMPETENCY TRAINED David Goger Clinician LCSW No Tomasann Miller Clinician AMFT No

2 Amy Harper Clinician AMFT No Compass Family Counseling Services 5320 Hwy 49 South (559) Services Provided: Adult and Children ADA Compliant Facility: Yes STAFF NAME PROVIDER LICENSE TYPE CA LICENSE # NPI # COMPETENCY TRAINED Carol Windsor Clinician LMFT Yes Allison Kay Livermore Clinician AMFT Yes Christian Nicole Record- Jackson Clinician AMFT Yes Jenni Buczko 5078 Bullion Street (209) Services Provided: Adult Only ADA Compliant Facility: No LICENSE CA STAFF NAME PROVIDER TYPE LICENSE # NPI # COMPETENCY TRAINED Jenni Buczko Clinician LPCC Yes Services may be delivered by an individual provider or a team of providers who is working under the direction of a licensed practitioner operating within their scope of practice. Only licensed, waivered, or registered mental health providers and licensed substance use disorder services providers are listed on the Plan's provider directory. Interpreter services are available free of charge in other languages. Updated 8/9/18 de

3 LANGUAGE ASSISTANCE English ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: ). ATTENTION: Auxiliary aids and services, including but not limited to large print documents and alternative formats, are available to you free of charge upon request. Call (TTY: ). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ). 번으로 전화해주십시오.

4 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ). Հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY: ). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: ). توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با )TTY: ( تماس بگیرید. (Farsi) ف ار سی 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ). まで お電話にてご連絡ください Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. 6741). Hu rau (TTY: ਪ ਜ ਬ (Punjabi) ਧ ਆਨ ਧ ਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲ ਹ, ਤ ਭ ਸ਼ ਧ ਚ ਸਹ ਇਤ ਸ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬ ਹ (TTY: ). 'ਤ ਕ ਲ ਕਰ

5 ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. (Arabic) ال عرب ية اتصل برقم )رقم هاتف الصم والبكم: ह द (Hindi) ध य न द : यदद आप द द ब लत त आपक दलए म फ त म भ ष स यत स व ए उपलब ध (TTY: ) पर क ल कर ภาษาไทย (Thai) เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: ) ខ ម រ (Cambodian) ប រយ ត ន ររ ស នជ អ នកន យ យ ភ ស ខ ម, រ វ ជ ន យមននកភ ស ស យម នគ ត លន គ អ ចម ន ររ អ ស នក ច ទ ព ទ (TTY: ) ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມພ ອມໃຫ ທ ານ. ໂທຣ (TTY: )

Notice of Appeal Resolution

Notice of Appeal Resolution Behavioral Health Services Department Quality Assurance Program PO Box 28504 San Jose, California 95159-8504 Tel. (408) 793-5894 Fax. (408) 288-6113 Notice of Appeal Resolution DATE Beneficiary s Name

More information

FRM016178CO00 (10/17)

FRM016178CO00 (10/17) Y0020_18_2827FORM_3836_CHI Accepted 07302017 FRM016178CO00 (10/17) Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin,

More information

Notice of Appeal Resolution

Notice of Appeal Resolution Notice of Appeal Resolution DATE Beneficiary s Name Address City, State Zip Treating Provider s Name Address City, State Zip RE: Service Requested You or Name of requesting provider or authorized representative,

More information

NOTICE OF ADVERSE BENEFIT DETERMINATION About Your Treatment Request

NOTICE OF ADVERSE BENEFIT DETERMINATION About Your Treatment Request NOTICE OF ADVERSE BENEFIT DETERMINATION About Your Treatment Request DATE Beneficiary s Name Address City, State Zip Treating Provider s Name Address City, State Zip RE: Service Requested You are currently

More information

Health Net Transition of Care Form. Welcome to Health Net! To be completed by agent: New member medical care checklist. Agent name M M D D Y Y Y Y

Health Net Transition of Care Form. Welcome to Health Net! To be completed by agent: New member medical care checklist. Agent name M M D D Y Y Y Y Health Net Transition of Care Form To be completed by agent: Agent name Health plan name Health plan start date New member medical care checklist Welcome to Health Net! As a new Health Net member, we want

More information

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory This pharmacy directory is updated monthly For more recent information or other questions, please contact

More information

COMPOUNDED PRESCRIPTION DRUG PRODUCTS

COMPOUNDED PRESCRIPTION DRUG PRODUCTS COMPOUNDED PRESCRIPTION DRUG PRODUCTS UTILIZATION MANAGEMENT CRITERIA COVERAGE AUTHORIZATION CRITERIA Compounded drug products whose total prescription ingredient cost is $200 or more are covered only

More information

Grass Valley, CA

Grass Valley, CA Nevada County Behavioral Health Provider List Adult Individual Providers In order to receive therapy, please contact Nevada County Behavioral Health at 530-265-1437 A clinician will speak with you about

More information

Member Grievance Form

Member Grievance Form Member Grievance Form Member Name: Last First Middle Initial Member Address: Phone: City: State: Zip Code: Member ID#: Birthdate: Sex: Primary Care Provider Name: Complaint Where did the problem happen?

More information

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina.

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina. SBOSB026 2018 Summary of Benefits Humana Walmart Rx Plan (PDP) State of North Carolina Our service area includes the following state(s): North Carolina. Other pharmacies are available in our network. GNHH4HIEN_18

More information

Grass Valley, CA

Grass Valley, CA Nevada County Behavioral Health Provider List Adult Individual Providers In order to receive therapy, please contact Nevada County Behavioral Health at 530-265-1437 A clinician will speak with you about

More information

2018 PDP Summary of Benefits

2018 PDP Summary of Benefits 2018 PDP Summary of Benefits Contracts S5540-002, S5540-004 January 1, 2018 December 31, 2018, SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an

More information

2019 Drug List Negative Changes Updated 02/26/2019

2019 Drug List Negative Changes Updated 02/26/2019 2019 Drug List Negative Changes Updated 02/26/2019 If you are taking a drug that is removed from the drug list, we will tell you. We will also tell you if we add any restrictions on a drug. We will tell

More information

2019 Formulary Monthly Notice of Change

2019 Formulary Monthly Notice of Change Updated: 03/01/2019 2019 Formulary Monthly Notice of Change Medicare Advantage Employer Group Plans (EGWP) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete

More information

Kadlec Regional Medical Center 0118 KMC-002B

Kadlec Regional Medical Center 0118 KMC-002B Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d n

More information

SENSIPAR 1 (CINACALCET) UTILIZATION MANAGEMENT CRITERIA

SENSIPAR 1 (CINACALCET) UTILIZATION MANAGEMENT CRITERIA SENSIPAR 1 (CINACALCET) UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: Calcium-Sensing Receptor Agonist BRAND (generic) NAMES: Sensipar (cinacalcet) 30 mg, 60 mg, 90 mg strength tablets FDA-APPROVED INDICATIONS

More information

Our dental plan for individuals age 65 and over

Our dental plan for individuals age 65 and over 2017 Dental plan information Our dental plan for individuals age 65 and over bcbsnc.com/dentalblueseniors What you get 1 + Affordable premiums with easy ways to pay + No wait for preventive services (which

More information

County of Marin Behavioral Health and Recovery Services Drug Medi-Cal Organized Delivery System (DMC-ODS) Provider List

County of Marin Behavioral Health and Recovery Services Drug Medi-Cal Organized Delivery System (DMC-ODS) Provider List County of Marin Behavioral Health and Recovery Services Drug Medi-Cal Organized Delivery System (DMC-ODS) Provider List As Marin County Medi-Cal beneficiaries, if you think you are or a family member needs

More information

UTILIZATION MANAGEMENT CRITERIA

UTILIZATION MANAGEMENT CRITERIA Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: PCSK9 Inhibitor BR (generic) NAMES: Praluent 1 (alirocumab) 75 mg/ml; 150 mg/ml Repatha 1 (evolocumab)

More information

Page 1. Utilization Management Policy Name: Topical Tretinoin Products Restricted Product(s): Unrestricted/Suggested Alternative(s):

Page 1. Utilization Management Policy Name: Topical Tretinoin Products Restricted Product(s): Unrestricted/Suggested Alternative(s): Utilization Management Policy Name: Topical Tretinoin Products Restricted Product(s): All topical tretinoin containing products require medical necessity review Atralin (tretinoin) Altreno (tretinoin)

More information

BUPROPION/NALTREXONE (Contrave 1 ) LORCASERIN (Belviq 1, Belviq XR 1 ) PHENTERMINE/TOPIRAMATE ER (Qsymia 1 )

BUPROPION/NALTREXONE (Contrave 1 ) LORCASERIN (Belviq 1, Belviq XR 1 ) PHENTERMINE/TOPIRAMATE ER (Qsymia 1 ) BUPROPION/NALTREXONE (Contrave 1 ) LORCASERIN (Belviq 1, Belviq XR 1 ) PHENTERMINE/TOPIRAMATE ER (Qsymia 1 ) UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: Obesity BRAND (generic) NAMES: Belviq (lorcaserin)

More information

Notice of Denial of Medical Coverage

Notice of Denial of Medical Coverage Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under Get help & more information.

More information

CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX. PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No

CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX. PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No ORAL DRUGS FOR PULMONARY ARTERIAL HYPERTENSION (PAH) BOSENTAN (Tracleer ), AMBRISENTAN (Letairis ), SILDENAFIL (Revatio ), TADALAFIL (Adcirca ), RIOCIGUAT (Adempas ), MACITENTAN (Opsumit ), TREPROSTINIL

More information

Doxazosin Dutasteride Finasteride Tamsulosin Viagra (sildenafil) benefit limitations apply

Doxazosin Dutasteride Finasteride Tamsulosin Viagra (sildenafil) benefit limitations apply Utilization Management Policy Name: Cialis Restricted Product(s): Cialis (tadalafil) Tadalafil (Cialis) (for BPH) Unrestricted Suggested Alternative(s): Doxazosin Dutasteride Finasteride Tamsulosin Viagra

More information

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico*

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico* 209 Over-the-Counter Drugs and Vitamins - Puerto Rico* Federal Employees Health Benefits Program Effective January, 209 OVER-THE COUNTER COVERAGE FOR PUERTO RICO CATEGORY PRODUCT LIMIT Allegra-D 2 Hour

More information

Indemnity PPO Medical Plan Preventive Care Guidelines

Indemnity PPO Medical Plan Preventive Care Guidelines Southern California Drug Benefit Fund Indemnity PPO Medical Plan Preventive Care Guidelines - 2018 The Indemnity PPO Medical Plan pays 100% of the cost of coverage for many routine preventive care services

More information

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus You have the right to appeal our decision You have the right to ask Blue Cross of Idaho Care Plus to review our decision by asking us for an appeal. If you lose the Medicaid services appeal with Blue Cross

More information

Member Handbook. Access Dental Plan Los Angeles County. Combined Evidence of Coverage and Disclosure Form

Member Handbook. Access Dental Plan Los Angeles County. Combined Evidence of Coverage and Disclosure Form Member Handbook What you need to know about your benefits Access Dental Plan Combined Evidence of Coverage and Disclosure Form 2018 Los Angeles County Page 2 of 48 1. Other languages and formats Other

More information

TRIPTAN RESTRICTED ACCESS; QUANTITY LIMIT EXCEPTION CERTIFICATION FAX REQUEST FORM

TRIPTAN RESTRICTED ACCESS; QUANTITY LIMIT EXCEPTION CERTIFICATION FAX REQUEST FORM TRIPTAN RESTRICTED ACCESS; QUANTITY LIMIT EXCEPTION CERTIFICATION FAX REQUEST FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5 DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Kaiser Permanente 2018 Sample Fee List *

Kaiser Permanente 2018 Sample Fee List * Kaiser Permanente 2018 Sample Fee List * What s a Sample Fee List? NORTHWEST Knowing how much you can expect to pay for care and services can help give you peace of mind. As a deductible plan member, you

More information

NONDISCRIMINATION NOTICE

NONDISCRIMINATION NOTICE NONDISCRIMINATION NOTICE Discrimination is against the law. Community Health Group follows Federal civil rights laws. Community Health Group does not discriminate, exclude people, or treat them differently

More information

YOUR DENTAL HEALTH IS OUR CAUSE DENTAL CHOICE (PPO) kp.org/dental/nw

YOUR DENTAL HEALTH IS OUR CAUSE DENTAL CHOICE (PPO) kp.org/dental/nw YOUR DENTAL HEALTH IS OUR CAUSE DENTAL CHOICE (PPO) kp.org/dental/nw 258275553_DENT_08-18 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

ATTENTION- DEFICIT HYPERACTIVITY DISORDER (ADHD) PRIOR REVIEW/CERTIFICATION FAXBACK FORM

ATTENTION- DEFICIT HYPERACTIVITY DISORDER (ADHD) PRIOR REVIEW/CERTIFICATION FAXBACK FORM ATTENTION- DEFICIT HYPERACTIVITY DISORDER (ADHD) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW

More information

ATYPICAL ANTIPSYCHOTICS

ATYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS UTILIZATION MANAGEMENT CRITERIA DRUG CLASSES: Second Generation (Atypical) Antipsychotics BRAND (generic) NAMES: Restricted Access Agents: Abilify Discmelt (aripiprazole), Fanapt

More information

Coverage for: Individual and Eligible Family

Coverage for: Individual and Eligible Family Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2018 06/30/2019 Regence BlueCross BlueShield of Oregon: Expressions SM Coverage for: Individual

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE GCHJMJXEN 0916 LIVE HEALTHY ENJOY REWARDS Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Small group quote request

Small group quote request Small Business Group Small group quote request (for groups with 1 50 employees) Requested effective date: First of (month) Send quote to: Producer Company contact person via: Email Fax Mail 1. PLEASE TELL

More information

Growth Hormones (GH) UTILIZATION MANAGEMENT CRITERIA

Growth Hormones (GH) UTILIZATION MANAGEMENT CRITERIA Growth Hormones (GH) UTILIZATION MANAGEMENT CRITERIA DRUG CLASS Synthetic recombinant Growth Hormone (Somatropin) BRAND NAMES: Genotropin Humatrope, HumatroPen Norditropin Nordiflex, Norditropin Flexpro

More information

Healthy Moves. A better flu season for you

Healthy Moves. A better flu season for you Fall/Winter 2017 Healthy Moves A better flu season for you Adults 65 years of age and older are a higher risk for getting and developing serious risks from the flu. Some of the risks are bronchitis, sinus

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS BASIC DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS (& CHILDREN AGE 19 THROUGH 25) PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person

More information

Getting to the BOTTOM OF BACK PAIN

Getting to the BOTTOM OF BACK PAIN Getting to the BOTTOM OF BACK PAIN What You Should Know About Low Back Pain Do I Need an X-ray? According to the American College of Physicians, most people with low back pain feel better after a month

More information

CheckUp. Today. Free Diabetes Education Class. Sign Up. Fall More Diabetes Tips

CheckUp. Today. Free Diabetes Education Class. Sign Up. Fall More Diabetes Tips CheckUp Fall 2018 Sign Up Today Protect your good health by attending the free Healthy Living with Diabetes class. Here are the upcoming class dates in Madison: September 26 November 1, 2018 5 7:30 pm

More information

GCHJUV2EN Member Registration Guide

GCHJUV2EN Member Registration Guide GCHJUV2EN 0417 Member Registration Guide Go365 Trilogy Member Registration Instructions Two Ways to Register for Go365 1. Go365.com 2. Go365 App (available in the Apple and Google Play Stores) Select the

More information

Small group quote request (for groups with 1 to 50 employees)

Small group quote request (for groups with 1 to 50 employees) A BETTER WAY TO TAKE CARE OF BUSINESS SMALL GROUP WASHINGTON Small group quote request (for groups with 1 to 50 employees) Requested effective date: First of (month) Send quote to: Producer Company contact

More information

2019 Summary of Benefits Medicare Prescription Drug Plans. BlueMedicare Value Rx (PDP) S

2019 Summary of Benefits Medicare Prescription Drug Plans. BlueMedicare Value Rx (PDP) S 2019 Summary of Benefits Medicare Prescription Drug Plans BlueMedicare Value Rx (PDP) S5904-006 January 1, 2019 December 31, 2019 The plan s service area includes: State of Florida 1 Y0011_92839_M 0818

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS DELUXE DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS AGE 19 & OLDER PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person for all covered

More information

Page 1. Unrestricted/Suggested Alternative(s): generic formulations of ADHD medications unless otherwise noted. Quantity limits apply.

Page 1. Unrestricted/Suggested Alternative(s): generic formulations of ADHD medications unless otherwise noted. Quantity limits apply. Utilization Management Policy Name: Attention Deficit Hyperactive Disorder (ADHD) Restricted Product(s): restriction is on branded products unless otherwise noted. Quantity restrictions apply to brand

More information

Your Feelings Matter WITH TYPE 2 DIABETES

Your Feelings Matter WITH TYPE 2 DIABETES Your Feelings Matter WITH TYPE 2 DIABETES A new diagnosis of type 2 diabetes may trigger a range of emotions from minor stress to major depression. Recognizing and addressing emotional reactions can play

More information

Take Charge of YOUR COPD

Take Charge of YOUR COPD Take Charge of YOUR COPD You are the Key Did you know that Chronic Obstructive Pulmonary Disease (COPD) Flare-Ups cause your COPD to progress faster and shorten your life? The key is managing your COPD

More information

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC What is Strep? Strep or strep throat is also known as Streptococcal Pharyngitis. Pharyngitis is a type of sore throat and is a

More information

Optional Supplemental Benefits Gold Benefits Enrollment Form

Optional Supplemental Benefits Gold Benefits Enrollment Form Optional Supplemental Benefits Gold Benefits Enrollment Form Health Net Medicare Advantage Plans Health Net offers optional supplemental benefits Gold Benefits for an additional monthly premium to our

More information

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK?

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? A previous heart attack increases your risk of having a second one. However, you can make changes to prevent a second heart

More information

Healthy Moves. Top Five Tips for Aging Better. Summer 2017

Healthy Moves. Top Five Tips for Aging Better. Summer 2017 Summer 2017 Healthy Moves Top Five Tips for Aging Better Aging is a natural process. Although, you cannot stop the clock, you can make the process smoother. Here are five tips to help you age better: 1.

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS INDIVIDUAL DENTAL PLAN FOR CHILDREN Summary of Dental Benefits Effective January 1, 2019 CHILDREN BENEFIT ENDS AT AGE 26 MAXIMUM OUT OF POCKET (MOOP) $350 per child or $700 for 2 or more children,

More information

Complete. Pennsylvania. How your plan works. Calendar year deductible This is the amount you will pay out-of-pocket for services in a calendar year

Complete. Pennsylvania. How your plan works. Calendar year deductible This is the amount you will pay out-of-pocket for services in a calendar year Complete Individual Dental Pennsylvania About your plan Good health starts with a healthy mouth. Regular dental exams and cleanings can lower the risk of gum disease, which is linked to heart disease,

More information

Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax:

Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax: Josette E. Spotts, MD, FACS 1485 W. Warm Springs Road, Suite 105 Henderson, NV 89014 Tel: 702.990.6360 Fax: 702.990.6363 Patient Name: Date: Age: Referred by: Reason for visit: Patient Name: Medical History

More information

Healthy. Now. vaccines? Is your child up to date on. page 4. Keep blood pressure in check with this healthy low-sodium recipe.

Healthy. Now. vaccines? Is your child up to date on. page 4. Keep blood pressure in check with this healthy low-sodium recipe. Healthy SPRING 2017 Now www.amerihealthcaritasia.com Is your child up to date on vaccines? page 4 Keep blood pressure in check with this healthy low-sodium recipe. See page 6 Tips for caregivers 2 Kids

More information

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: Non-Discrimination Statement As a recipient of Federal financial assistance, Aegis Therapies complies with applicable Federal Civil Rights laws and does not exclude, deny benefits to, or otherwise discriminate

More information

Preventive Health Care Guide Adults. Save and share with your doctor! Primary Care Office Visits. Screening Schedule. Immunization Schedule

Preventive Health Care Guide Adults. Save and share with your doctor! Primary Care Office Visits. Screening Schedule. Immunization Schedule Preventive Health Care Guide 2016 2017 At any stage of life, it s important to make your health a priority. That means making healthy lifestyle choices and seeing your doctor regularly. The charts on the

More information

HealthyFocus Spring 2017

HealthyFocus Spring 2017 HealthyFocus Spring 2017 Thanks for Your Feedback. We re Listening! Every year, the Oregon Health Authority (OHA) puts out a survey called the Consumer Assessment of Healthcare Providers and System, or

More information

PRESCRIBER ADDRESS CITY STATE ZIP. PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER

PRESCRIBER ADDRESS CITY STATE ZIP. PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER GENERAL AUTHORIZATION/QUANTITY LIMIT EXCEPTION CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME

More information

Regence Expressions Active Dental Plan Highlights for Groups 51+ 1/1/2018

Regence Expressions Active Dental Plan Highlights for Groups 51+ 1/1/2018 Plan Features This plan includes preventive and diagnostic services, as well as restorative and major services. After satisfaction of the deductible, this plan will provide payment for the services at

More information

Personal Dental Coverage with Optional VisionBlueSM. Affordable Dental Plans for Individuals of All Ages

Personal Dental Coverage with Optional VisionBlueSM. Affordable Dental Plans for Individuals of All Ages Personal Dental Coverage with Optional VisionBlueSM Affordable Dental Plans for Individuals of All Ages When it comes to maintaining a healthy body, a good place to start is a healthy mouth. BlueCross

More information

Living with DIABETES

Living with DIABETES Living with DIABETES Mark Your Calendar Regular tests and screenings can ensure you re on the right track with your Diabetes. You should complete the following screenings at least once or twice a year:

More information

CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX. PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No

CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX. PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No IMMEDIATE RELEASE OPIOID 7 DAY FIRST FILL AND QUANTITY LIMIT EXCEPTION PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR -DIGIT Blue Cross

More information

Granite Alliance Insurance Company (PDP) 2019 Step Therapy Criteria

Granite Alliance Insurance Company (PDP) 2019 Step Therapy Criteria Granite Alliance Insurance Company (PDP) 2019 Step Therapy Criteria Last Approved: 02/20/2019 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step

More information

Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and

Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law Radiologic Associates, PC complies

More information

2018 Preventive Medication List

2018 Preventive Medication List 2018 Preventive Medication List Introduction In addition to a healthy lifestyle, preventive medications are important in helping people avoid many types of illnesses and complications from illnesses. This

More information

Kaiser Permanente 2018 Sample Fee List *

Kaiser Permanente 2018 Sample Fee List * Kaiser Permanente 2018 Sample Fee List * COLORADO What s a Sample Fee List? Knowing how much you can expect to pay for care and services can help give you peace of mind. As a deductible plan member, you

More information

Preventive Drug List

Preventive Drug List 2018 Preventive Drug List Introduction In addition to a healthy lifestyle, preventive prescription drugs are important in helping people avoid many types of illnesses and complications from illnesses.

More information

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky 1. Nondiscrimination Notice and Accessibility Requirements. ENT & Allergy Specialists will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and

More information

Health TALK. Mammograms save lives. Plan to quit.

Health TALK. Mammograms save lives. Plan to quit. Health TALK FALL 2018 Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day. Or it could be the fi rst day of a permanent, healthy

More information

Summary of Benefits. January 1, 2017 December 31, 2017

Summary of Benefits. January 1, 2017 December 31, 2017 Summary of Benefits January 1, 2017 December 31, 2017 This is a summary of drug services covered by Regence Medicare Script Basic (PDP) or Regence Medicare Script Enhanced (PDP). S5916_PDP_UT_2017_SB V2

More information

APPOINTMENT OF REPRESENTATIVE

APPOINTMENT OF REPRESENTATIVE PO Box 31368 Tampa, FL 33631-3368 APPOINTMENT OF REPRESENTATIVE Name: Member number: Reference/Case number: PART 1 --- APPOINTMENT OF REPRESENTATIVE (to be filled out by member) I allow (Name of person

More information

Appeals & Grievances Department REQUEST FOR RECONSIDERATION (APPEAL) Part C MEMBER NAME: HNET Member ID Number:

Appeals & Grievances Department REQUEST FOR RECONSIDERATION (APPEAL) Part C MEMBER NAME: HNET Member ID Number: Health Net Medicare Programs P.O. Box 10344 Van Nuys, CA 91410-0344 Phone: 1-800-431-9007 TTY: 711 Fax: 1-877-713-6189 Health Net Medicare Programs Appeals & Grievances Department REQUEST FOR RECONSIDERATION

More information

HealthyFocus. Fall Winter Is Coming. At Home. In this issue:

HealthyFocus. Fall Winter Is Coming. At Home. In this issue: HealthyFocus Fall 2017 Winter Is Coming If you re a glass-half-full person, winter may make you think of pumpkin pie spice, fall leaves, football, special meals, and twinkling lights. But as the glass-half-empty

More information

2017 Part D Model LIS Premium Summary Table for Those Receiving Extra Help

2017 Part D Model LIS Premium Summary Table for Those Receiving Extra Help 2017 Part D Model LIS Premium Summary Table for Those Receiving Extra Help Health Net Jade (HMO SNP) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription

More information

Family and Self Health History for Genetic Counseling. Your Personal Health History

Family and Self Health History for Genetic Counseling. Your Personal Health History Family and Self Health History for Genetic Counseling Your Personal Health History NAME: DATE OF BIRTH: 1. Your weight: (pounds) Your height: feet inches 2. Have you ever had cancer? YES NO If YES, please

More information

Request for Redetermination of Medicare Prescription Drug Denial

Request for Redetermination of Medicare Prescription Drug Denial Request for Redetermination of Medicare Prescription Drug Denial Because we, Health Net Medicare Programs, denied your request for coverage of (or payment for) a prescription drug, you have the right to

More information

GET REWARDED. by connecting your fitness device to Go365 COMPATIBLE FITNESS DEVICES GCHJHTFEN 0718

GET REWARDED. by connecting your fitness device to Go365 COMPATIBLE FITNESS DEVICES GCHJHTFEN 0718 COMPATIBLE FITNESS DEVICES GET REWARDED by connecting your fitness device to Go365 GCHJHTFEN 0718 EARN POINTS USING DEVICES FROM THESE MANUFACTURERS Points awarded for verified workouts available on Go365.com

More information

Federal DentalBlue. Standard and Basic Options

Federal DentalBlue. Standard and Basic Options Federal DentalBlue Standard and Basic Options Effective January 1, 2018 Federal DentalBlue Standard Option 2018 Deductible Maximum Benefit Diagnostic and Preventive Basic Restorative Services Endodontics,

More information

Member Matters Newsletter

Member Matters Newsletter Member Matters Newsletter 2017 Winter Issue IN THIS ISSUE 2 A New Year with Premier HealthOne 2 Is it Time to See Your Doctor? 3 Chicken & White Bean Soup 4-5 Preventive Health Checklist 6-7 Recognizing

More information

The benefit of knowing

The benefit of knowing The benefit of knowing Genetic testing for familial hypercholesterolemia (FH) A patient support guide 2 Does high cholesterol run in your family? In some families, high cholesterol is caused by familial

More information

CCCN Patient Questionnaire

CCCN Patient Questionnaire CCCN Patient Questionnaire Date: Patient Name: Age: Referred by: Primary Care Physician: Please provide names and phone numbers of your physicians (primary care, medical oncologist, surgeon, etc.): Reason

More information

A healthy smile just got easier with our dental benefit!

A healthy smile just got easier with our dental benefit! A healthy smile just got easier with our dental benefit! 2018 TX MMP ACCESS How do I access the benefit? A ENEFIT As a member of the Molina Dual Options STAR+PLUS MMP, you get the added benefit of supplemental

More information

Dental Blue 65. Outline of Coverage. Dental Blue 65 Preventive Dental Blue 65 Basic Dental Blue 65 Premier Effective January 1, 2017

Dental Blue 65. Outline of Coverage. Dental Blue 65 Preventive Dental Blue 65 Basic Dental Blue 65 Premier Effective January 1, 2017 Dental Blue 65 Outline of Coverage Policy Number: DENT SR (1 1 2012) Read your subscriber certificate carefully. This disclosure statement is a very brief summary of your dental plan. The plan itself sets

More information

You can get this document in another language, large print, or another way that s best for you. Call (800) , TTY (800)

You can get this document in another language, large print, or another way that s best for you. Call (800) , TTY (800) Primary Care Provider (PCP) Change Form Usted puede recibir este documento en otro idioma, impreso en letra más grande o de cualquier otra manera que sea mejor para usted. Llame al número gratuito (800)

More information

Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused or expired prescription drugs.

Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused or expired prescription drugs. 1 GRAB-AND-GO EMPLOYEE EDUCATION CAMPAIGN HOW-TO GUIDE National Prescription Drug Take-Back Day Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused

More information

2018 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California

2018 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California 2018 Preventive/Comprehensive Dental HMO Plan Health Net Medicare Advantage Plans California Y0020_18_4264BKLT Accepted 01232018 2018 Preventive/Comprehensive Dental HMO Plan The following information

More information

Luana i ke ola maika i

Luana i ke ola maika i OCTOBER 2018 Luana i ke ola maika i Enjoying good health Tips for a lifetime of good health and well-being are here. IN THIS ISSUE: Open Enrollment: Stick With HMSA We re More than What You d Expect We

More information

Warfarin. (Coumadin, Jantoven ) Taking your medication safely

Warfarin. (Coumadin, Jantoven ) Taking your medication safely Warfarin (Coumadin, Jantoven ) Taking your medication safely Welcome This booklet is designed to provide you with important information about warfarin to help you take this medication safely and effectively.

More information

2018 Preventive Drug List

2018 Preventive Drug List 2018 Preventive Drug List Introduction In addition to a healthy lifestyle, preventive prescription drugs are important in helping people avoid many types of illnesses and complications from illnesses.

More information

Kaiser Permanente 2018 Pharmacy Directory

Kaiser Permanente 2018 Pharmacy Directory Kaiser Permanente 2018 Pharmacy Directory This pharmacy directory was updated on 08/2017. For more recent information or other questions, please contact Kaiser Permanente Member Services at 1-800-232-4404

More information

QUANTITY LIMIT EXCEPTION PRIOR REVIEW/CERTIFICATION FAXBACK FORM

QUANTITY LIMIT EXCEPTION PRIOR REVIEW/CERTIFICATION FAXBACK FORM QUANTITY LIMIT EXCEPTION PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME PRESCRIBER

More information

SELECTIONS. Welcome to the UPMC MyHealth Selections program

SELECTIONS. Welcome to the UPMC MyHealth Selections program SELECTIONS Welcome to the UPMC MyHealth Selections program Congratulations on taking this step toward a healthier lifestyle! By taking part in the UPMC MyHealth Selections program you are showing that

More information