Your Guide to Prestige Health Choice

Transcription

1 Your Guide to Prestige Health Choice Prestige Health Choice 1

2 Table of Contents Welcome to Prestige Health Choice... 2 Enrolling... 3 Your member ID card... 5 Your primary care provider (PCP)... 6 More about your PCP... 8 Helpful questions... 9 When someone is sick or hurt Your Prestige benefits Your rights and responsibilities More about Prestige Important phone numbers and information Your notes Non-discrimination notice and language services This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. Prestige Health Choice 1

3 Welcome to Prestige Health Choice Thank you for choosing Prestige. Prestige works with you and your family to keep you healthy. This member handbook tells you about the benefits of Prestige and how the plan can help you. The more you know about Prestige, the better we can serve you and your family. The decision whether or not to join Prestige will not affect your eligibility for Medicaid benefits. The Prestige provider directory can be found online at The provider directory is a list of participating providers along with their addresses, phone numbers, and specialties. It also shows whether a provider is seeing new patients. To find out more information about a primary care provider (PCP) or specialist or to request a printed paper copy of the provider directory, call Member Services at (TTY/TDD ). If a Prestige associate calls you, we will identify ourselves by name, job title, and the area of the health plan we work in (i.e., Member Services). If you are unsure about speaking with someone who calls you, please gather the information we have provided and let the caller know that you will call Prestige back. Call Member Services at and ask for the person you just spoke with by name, job title, and department. This way you can feel confident that you are speaking with a Prestige associate. We look forward to serving you and your family and keeping you healthy. If you have any questions about the health plan, please call Member Services at (TTY/TDD ). Member Services toll free: hours a day, 7 days a week TTY for hearing impaired toll free: hours a day, 7 days a week Toll-free Nurse Call Line: Get health information from a registered nurse 24 hours a day, 7 days a week. In Other Languages and Formats We ll provide the information in this handbook to you in other languages and formats at no charge. We ll also interpret this information over the phone in any language. Call Member Services at If you are deaf or have trouble hearing, our TTY/ TDD number is Charges for local and long-distance relay calls will be the same as your regular local and long-distance calling plan. Nosotros le podemos ofrecer esta información a usted en otros idiomas y formatos sin costo. También interpretaremos esta información por teléfono en cualquier idioma. Llame a Servicios al Miembro al Si usted es sordo o tiene problemas auditivos, nuestro número TTY/TDD es Los cargos para llamada relé locales o de larga distancia serán los mismos que su plan regular para llamadas locales o de large distancia. N ap ba w enfòmasyon ki nan ti liv sa a nan lòt lang ak nan lòt fòma san w pa bezwen peye pou sa. Mete sou sa, n ap entèprete enfòmasyon sa yo nan telefòn nan nenpòt lang. Rele Sèvis manm nan Si w soud oswa si w pa tande byen, nimewo TTY/TDD nou an se Lè w pase yon koutfil ak sèvis relè lokal oswa long distans pou moun ki pa tande byen, ou peye menm kòb ou ta peye pou yon koutfil lokal oswa long distans selon plan sèvis telefòn ou an. 2 Prestige Health Choice

4 Enrolling When you are eligible for Medicaid, you need to choose a health plan. The Florida Department of Children and Families (DCF) determines who is eligible for Medicaid. Medicaid Choice Counseling can help you enroll with a Medicaid plan. They have enrollment specialists who can: Help you and your family enroll in a health plan. Answer questions about your choice of health plans. Help you if you decide to change health plans. You can talk to an enrollment specialist at Medicaid Choice Counseling by calling toll free at (TTY/TDD ). You can also enroll by going to Once you enroll in Prestige, we send you a welcome kit. Open enrollment If you are a mandatory enrollee, the state will send you a letter in 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called open enrollment. You do not have to change managed care plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you may change managed care plans during your 60 day open enrollment period, without cause. Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Prestige or the state enrolls you in a plan, you will have 120 days from the date of your first enrollment to try the managed care plan. During the first 120 days, you can change managed care plans for any reason. After the 120 days, if you are still eligible for Medicaid, you may be enrolled in the plan for the next 8 months. This is called lock-in. Prestige Health Choice 3

5 Enrolling How do I enroll my newborn? Prestige will cover your baby the day he or she is born. We will need your help to make sure we enroll your baby right away. Here are some things you can do to help us get your baby Medicaid. 1. Call the Florida DCF toll free at while you are pregnant. This will make sure your baby has Medicaid from the day he or she is born. DCF will help you do this. They will give you a Medicaid number for your baby. 2. Call Prestige. Tell us the Medicaid number for your baby. You will need to pick a Prestige PCP for the baby before he or she is born. We can help you with this. If you do not pick a PCP by the time your baby is born, we will pick 1 for you. If you would like to change your baby s PCP, please call Prestige. 3. When the baby is born, call DCF and Prestige. The state will turn on your baby s Medicaid ID number once the hospital or provider tells the state that your baby has been born. Reinstatement to the plan If you lose your Medicaid eligibility, you ll be removed from our plan. But if you get it back within 180 days, you ll return to us. This is called reinstatement. We will send you a letter within 5 business days of your reinstatement. That letter will tell you the new date that you are a Prestige member. We will also tell you who your PCP will be and ask you to call us if you need a new member ID card or member handbook. This letter will also tell you if you are eligible for open enrollment and how to change plans if you have a state-approved good cause reason. Call Member Services if any information about you or your family changes. Call Member Services if your mailing address changes. You must also contact the Social Security Administration (SSA) at (TTY/TDD ) or DCF at with these changes. 4 Prestige Health Choice

6 Your member ID card Always carry it with you Every member of Prestige gets a member ID card. When you get your member ID card, make sure everything on it is correct. If you have not received your member ID card, or if it has been lost, please call Member Services at (TTY/TDD ). We will mail you a new card. Your member ID card is very important. You should carry it with you at all times. You must show your member ID card whenever you get services from doctors, hospitals, pharmacies, and other Prestige providers. Do not let anyone else use your member ID card. If you do, you may have to pay for the service, or you could lose your benefits. What s on your member ID card? Your name. Your Prestige ID number. Your date of birth. Effective date (the date you became a Prestige member). Your PCP s name, address, and phone number. Important information for pharmacies. Prestige Health Choice 5

7 Your primary care provider (PCP) A personal doctor for you When you join Prestige, you must choose a health care provider from the Prestige provider directory to help you get health care. This provider is your PCP. Your PCP s office is your medical home. Your medical home will provide medical services and advice on health matters. Your PCP will keep other providers you see informed of your medical records and advise whenever these records are needed. Be sure to have your medical records sent from any doctors you have seen in the past to your new PCP, if you have picked a new PCP. You can choose a different PCP for each family member or you can choose 1 PCP for the entire family. If you do not choose a PCP, Prestige will assign a PCP for you and your family. You can look for a PCP by using our provider directory at or we can help you find a PCP by calling Member Services. Providers in the Prestige provider directory have agreed to take care of Prestige members. These providers have met Prestige s standards for quality of care. Be sure to make an appointment with your PCP right away. Your PCP s phone number is on your member ID card. Your PCP cares about you and your health and arranges all your health care. When you need medical care, call your PCP s office first at any time, day or night. Your PCP will know how to help you. If you need to go to a specialist provider or to the hospital, your PCP can make all the plans for you. Some PCPs have trained health care assistants who work with them. They may help your PCP take care of you. There may be times when you will see 1 of these health care assistants. If you have questions, call Member Services at (TTY/TDD ). The types of assistants that may help your PCP are: Physician assistants. Medical residents. Nurse practitioners. Nurse midwives. Family practice, general practice, pediatric, some internal medicine, some OB/GYN providers, and some nurse practitioners can serve as your PCP. A specialist provider generally cannot serve as your PCP. Your PCP will: Listen to your health problems and answer all questions. Keep a record of your health history. Provide timely medical care to you. Give physical exams and immunizations (shots) when needed. Write prescriptions when needed. Educate you about good health habits and disease prevention. Refer you to a specialist provider when needed. Arrange for hospital care when needed. Explain your health problems and treatment you need to take care of them. Return phone calls as soon as possible. Treat you and your family with kindness and respect. 6 Prestige Health Choice

8 Your primary care provider (PCP) Dual eligible (Medicare and Medicaid) If you have Medicare and are eligible for Medicaid benefits, you are dual eligible. Dual-eligible members receive PCP services through Medicare and have a Medicare PCP. Dual-eligible members do not have to choose a new PCP through Prestige. Getting in touch with your PCP Your PCP is available to you 24 hours a day. However, it may be best to call during normal business hours if you want to talk to someone from the office. Here are the standards that Prestige and your PCP have agreed upon for making appointments: Emergencies will be seen right away. Urgent care will be seen within 1 day. Routine sick care will be scheduled within 1 week. Well-care visits will be scheduled within 1 month. If your PCP leaves Prestige: When we know that your PCP is leaving the Prestige network, we will let you know by mail and assign you a new PCP in your area. You may choose a different PCP by calling Member Services at (TTY/TDD ). Continuity of care In certain situations, you can continue ongoing treatment at no cost with a health care provider who is not in the Prestige network. This can happen when: You are a Prestige member who is getting ongoing treatment from a health care provider who is not in the Prestige network or has left the Prestige network. When this happens, Prestige will: Allow new members to receive ongoing care from a health care provider who is not in the Prestige network for up to 60 days from the date the member is enrolled in Prestige. Allow new members who are pregnant to get ongoing treatment from their current health care provider even if the provider is not in the Prestige network. You will be able to see this provider until the end of your postpartum care (up to 6 weeks after you deliver your baby). Allow members to get ongoing treatment from a health care provider who has left the Prestige network for up to 6 months from the date Prestige tells the member that the health care provider will no longer be in the Prestige network. For more information on continuity of care, call Member Services at (TTY/TDD ). You can also access the provider directory at Prestige Health Choice 7

9 More about your PCP Get to know your PCP Make an appointment with your PCP right away, before you get sick and need medical care. Call your PCP office and make an appointment for a medical checkup. Make your appointment as soon as you can. Arrange for transportation If getting to your appointment is a problem, please call The transportation vendor will assist you in getting transportation for covered services. Remember to call to schedule your ride as soon as you know your next appointment. The sooner you can call to schedule your ride, the easier it will be to arrange your transportation. You may also call Prestige Member Services at (TTY/TDD ) for help getting transportation. Please remember: If you can, try to call at least 2 business days before your appointment to schedule your ride. You can schedule your ride as early as 30 days before your appointment. You will need to know the street address, city, and ZIP code for the location of your appointment. You must have your Prestige ID number when you call to schedule your ride. At the office When you get to the PCP s office, you will need to give information about you or your family s health and medical history. Answer all of the questions as best you can. If there is something you do not understand, ask for help. This information is very important for your PCP to keep you and your family healthy. The PCP will then give you or your family member a medical checkup. He or she will also need to talk to you about your health or your family member s health. Ask as many questions as you like. You may always stay in the exam room with your child. Listen carefully to any directions the PCP gives you. If you do not understand what your PCP wants you to do, call the PCP s office day or night. Changing PCPs You may change your PCP by calling Member Services. We can help you choose another PCP in your area. You can also find a PCP by using the provider directory on our website at You will get a new member ID card when you change your PCP. When you get the new card, please destroy your old card. Call Member Services at (TTY/TDD ) for more information about changing your PCP. If you have an emergency, please call 911 right away. Keep your appointments It is important to be on time for your appointment. If you are going to be late or need to cancel your appointment, call the PCP s office ahead of time and let the office know. If you need to change your appointment, try to let your PCP s office know at least 24 hours before the appointment. 8 Prestige Health Choice

10 Helpful questions Helpful questions to get care from your PCP This list will help you with your medical concerns and questions. Answer the first set of questions before you visit your PCP. Your PCP will help you answer questions 2 through Tell your PCP what is wrong: a. If you have a problem, when did it start? b. What are the symptoms (signs)? c. Have you ever had this problem before? d. If so, when? What did you do about it? 2. Ask your PCP the following: a. What is the problem called? b. What will happen as a result of the problem? c. How do I treat myself at home? 3. If your PCP gives you medicine or treatment, ask your doctor the following: a. What is the name of the medicine or treatment? b. Why do I need to take it? c. What are the risks and side effects? d. What are the other choices? e. How do I take the medicine? f. How do I get ready for the treatment? 4. Before you leave your PCP s office, find out the following: a. Should I return for a follow-up appointment? b. Should I call for test results? If so, when? c. Are there any danger signs I need to look for? d. Is there anything else I need to know? Prestige Health Choice 9

11 When someone is sick or hurt Always call your PCP as soon as you can. If the problem is not an emergency, the PCP can arrange for you to come into the office for care. Emergency and urgent care An emergency is a health problem that may be serious and a danger to your life and ability to get around. The problem may be with any body part or organ. If you are pregnant, this includes you and your unborn baby. You should go to the hospital emergency room (ER) if you have a life-threatening illness or injury. If you are not sure that you have an emergency, call your PCP or our Nurse Call Line at If you have an emergency, call 911 or go to the nearest ER. Show your member ID card. Call your PCP and Prestige as soon as you can. You do not need prior authorization (pre-approval) to go to the ER. Urgent care is for medical conditions that require care within 48 hours. If you don t get treatment for the condition in 2 days or less, it could become an emergency. Follow-up care after an ER visit (post-stabilization care) After an emergency, you may need care to help your medical issue get better or go away. This is called post-stabilization care. Post-stabilization services are covered services related to an emergency medical condition. They are provided after your immediate medical or behavioral health problems are stabilized. Prestige does not require prior authorization for poststabilization care. 10 Prestige Health Choice

12 When someone is sick or hurt Nights and weekends Your PCP can help you 24 hours a day, 7 days a week. If you have a problem during the day, you should call your PCP right away. If you get sick after the PCP s office is closed, call the office anyway. Someone will answer, and the PCP will call you back. If you can t reach your PCP, call the Nurse Call Line at to get help. You may need to go to an urgent care center or to the ER. Here is a guide to help you decide if you should go to the ER: Call your PCP if you or your family member has: Sore throat Flu or cold Back pain Frequent urination Fever of 99º to 102º (adults and children 3 months old or older) Earaches Toothaches Call 911 or go to the ER if you or your family member has: A serious accident Eye damage Severe bleeding A fever of 100.5º or higher for infants 0 to 2 months old Severe cuts or burns Broken bone Blood in vomit A knife or gunshot wound Chest pain Difficulty breathing Unconsciousness Poisoning Nearly drowned No pulse or heartbeat A stroke Out of town If you or a family member get sick and need medical care when out of the Prestige service area, call Member Services at (TTY/TDD ). We will help you find a provider wherever you are. Prestige Health Choice 11

13 When someone is sick or hurt Specialists A specialist is a provider who practices a certain area of medicine. Your PCP is trained to treat most medical problems. However, there may be times when you need to see a provider who is a specialist. Your PCP will help you decide when to see a specialist and will help you see a Prestige specialist. Prestige covers your visits to contracted specialists in our network without prior authorization. There is no limit to how many times you may see a specialist. Specialists can include: Heart doctors (cardiologists). Skin doctors (dermatologists). Doctors for women s health (gynecologists). Doctors for pregnant women (obstetricians). Doctors for blood problems (hematologists). Doctors for bones and joints (orthopedists). Foot doctors (podiatrists). Eye doctors (ophthalmologists). Cancer doctors (oncologists). Behavioral health doctors (psychiatrists). Surgeons. Always check with your PCP before going to a specialist. You can see an OB/GYN at any time. For a list of Prestige specialists, call Member Services at (TTY/TDD ) or visit our website at Out-of-network specialists If you need to see a specialist who is not in the Prestige network, you will need to have prior authorization from Prestige. Ask your PCP to help you. You may have to pay for services if you see a provider that is not part of the Prestige network. Second opinion If you want to know what another provider says about your health problem, you may get a second opinion at no cost to you. Call Member Services at (TTY/TDD ) or ask your PCP for the name of another provider who is a Prestige provider. Make sure you have a referral form from your PCP or Prestige before calling the second provider. Call the second provider to make an appointment. You can get help by calling Member Services at (TTY/TDD ). Nurse Call Line Prestige members have access to a 24-hour Nurse Call Line. The Nurse Call Line is a free service you can call anytime. A nurse will listen to your health care problems or questions and help you make good health care decisions. The next time you are sick, hurt, or need health information, call the Nurse Call Line at If you want more information about a Prestige provider, call Member Services at (TTY/TDD ). You can find out things like where a specialist went to medical school or if they are board certified. 12 Prestige Health Choice

14 Your Prestige benefits Services covered by Prestige and what to do There are no copayments for the services listed below. But remember, you may be responsible for paying for services if you find out ahead of time that Prestige does not cover the services. You may also have to pay for the services if you go to a provider that is not in the Prestige network. It is important to check with your PCP or call Member Services at (TTY/TDD ) if you have questions. Services Adult well visits are regular medical checkups that help keep you healthy. Advanced registered nurse practitioner (ARNP) visits are visits to an advanced practice registered nurse who works with your PCP or other specialist to assist in your care. Assistive care services are only available if you live in an assisted living facility, adult family care home, or residential treatment facility. These services include health support and help with activities of daily living, instrumental activities of daily living, and taking your medication. Behavioral health services are inpatient and outpatient hospital services and psychiatric provider services. Mental health and case management services are available. You can get these services in the community and in your home. See the section on How to get behavioral health services on page 18 for more information. Birth center and midwife services. Birth centers provide care during low risk pregnancies, deliveries, postpartum care and newborn evaluations. Midwives provide obstetrical prenatal, labor and delivery, postpartum care and newborn evaluations. Child health checkups (CHCUPs) are regular medical checkups from birth to age 21; visits may include immunizations. See the CHCUP on page 25 for more information. Chiropractic services are limited to 1 visit per day and up to 24 visits a year. What to do Make an appointment with your PCP. Speak to your PCP or specialist. A health assessment must be completed by a licensed provider. Prior authorization is required. Make an appointment with a Prestige behavioral health care provider. Call Member Services at (TTY/TDD ) for a list of providers. Make an appointment with your child s PCP for these services. Make an appointment with a Prestige chiropractor. More than 24 visits per year may be approved for members under 21, if medically necessary. Prestige Health Choice 13

15 Your Prestige benefits Services Durable medical equipment (DME) includes medically necessary equipment and supplies when ordered by a provider. There are some limits for members ages 21 and older. Dental care for adults is a group of services for members ages 21 and older and includes emergency dental services, denture and denture-related services, and oral and maxillofacial surgery. They can receive 2 exams, 2 cleanings, 4 simple extractions, 2 surgical extractions, and 3 amalgam fillings per year and 1 x-ray every 2 years. Dental care for children is a group of dental services for members under the age of 21. Emergency transportation (ambulance) Eye care for adults is a group of services for members ages 21 and older and includes up to 1 eye exam and 1 pair of eyeglasses every 365 days. You may be able to get contact lenses. Talk to your PCP. Eye care for children is a group of services for members under the age of 21. The services include up to 2 eye exams and 2 pairs of eyeglasses every 365 days. You may be able to get contact lenses. Talk to your PCP. Family planning services let you plan the size of your family or think about when you want to have children. They include information, diagnostic procedures, medical tests, birth control drugs and supplies, sterilization, and follow up. Hearing services cover medically necessary hearing evaluations, diagnostic testing, hearing tests, and 1 hearing aid every other year. Cochlear implants are covered when medically necessary. Home health care services can include skilled nursing, home health aide, and physical, occupational and speech therapy services in your home. Occupational and speech therapy is not available in your home for members ages 21 and older. You will need a doctor s order (such as a prescription) for these services. What to do Call your PCP if you need DME services. Prior authorization is required for all DME services. Make an appointment with a participating dentist. Make an appointment with a participating dentist. Call 911 if there is an emergency. Make an appointment with a participating provider. Make an appointment with a participating provider. Make an appointment with a participating provider. Prior authorization is only required for sterilization services. Make an appointment with a participating provider. Prior authorization is required for cochlear implants. Call Member Services at (TTY/TDD ) if you need these services. Prior authorization is required for all home health care services. 14 Prestige Health Choice

16 Your Prestige benefits Services Hospice services are provided to terminally ill members. Hospice provides care and support for members who are determined by their provider to have 6 months or less to live due to a medical condition. These services are provided by a hospice agency. Inpatient care is a group of services provided under the direction of a doctor when you are admitted to a hospital for a stay that is more than 24 hours. It includes room and board, medical supplies and equipment, medications, and other hospital services. Lab and X-ray services include lab tests, portable X-rays, and diagnostic imaging. Diagnostic imaging includes magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET). In-network providers and laboratory facilities provide these services. In-network providers and laboratory facilities provide these services. Life-threatening emergencies are identified when medical care is needed right away because of a danger to your life, limb(s) or sight if not treated right away. Maternity services include nursing review and counseling, nutrition review, prenatal (pre-birth) services, delivery (having the baby), postpartum (after birth) services, and nursery services (your baby s care while in the hospital). See the section Special care for pregnant members on page 27 for more information. Medically-related lodging and food $1,000 per member, per year. Benefit is only available when travelling more than 100 miles from the member s home for medically necessary treatment. Treatment must be received from a participating provider in Florida. The benefit cannot be used to purchase alcohol. Non-emergency transportation is available for covered services. What to do Call Member Services at (TTY/TDD ) for a list of providers. Call your PCP. Prior authorization is required for all inpatient admissions. Call your PCP. Call 911 or go to the nearest ER. Call Member Services at (TTY/TDD ) for a list of providers. Call the Rapid Response and Outreach Team at for more information. Prior authorization is required. Please contact our transportation vendor at For questions, please contact Member Services at (TTY/TDD ). Prestige Health Choice 15

17 Your Prestige benefits Services Nursing facility services are for members ages 18 and under. Nursing facility services provide 24-hour medical and nursing care in a residential setting, institution, or distinct part of an institution. Outpatient services are preventive diagnostic, therapeutic, rehabilitative, surgical, and emergency services received for the treatment of a disease or injury at an outpatient or ambulatory care facility for a period of time under 24 hours. Pharmacy prescriptions and over-the-counter medicines. Prestige can give you a drug list that will tell you what medicines we cover. Coverage of over-the-counter medicine is limited to a maximum of $50 per year, per household. You can also see the drug list on our website at Click on Members and Find a doctor, medicine, pharmacy or transportation and then Find a medicine: printable preferred drug list. Podiatry services include routine foot care, diagnosis, and treatment of diseases and injuries of the foot. PCP visits are visits to the personal provider you chose from the Prestige provider directory. You may have a PCP visit in your home if medically necessary. Specialist visits are visits to a doctor who practices a certain area of medicine. Therapy services include physical, occupational, speech, and respiratory therapy for all members ages 20 and under. Prestige covers these therapies for members ages 21 and over, but there are some limits. Vaccinations for adult members ages 21 and older include influenza, pneumonia, and shingles shots. Well-woman visits include regular medical checkups for women, including annual mammograms and Pap tests. You can also access counseling or referral services not covered due to moral or religious objections. What to do Prior authorization is required for nursing facility services. Call your PCP. For questions, please contact Member Services at (TTY/TDD ). Talk to your PCP if you need these services. Call your PCP. Prior authorization is required for home visits. Talk to your PCP. Talk to your PCP if you need these services. Make an appointment with a participating provider. Talk to your PCP for more information. Contact Member Services for state service options. 16 Prestige Health Choice

18 Your Prestige benefits Prior authorization for medical services Prestige must approve some services before your doctor can help you get them. We call this prior authorization. Please talk to your doctor about the services you need and if they will need prior authorization. Prior authorization process Your doctor gives the information to Prestige for review. If a Prestige nurse cannot approve the request, a Prestige doctor will review the request. If Prestige approves the request, we will contact your doctor. If Prestige does not approve the request, we will send a letter to you and your doctor. We will tell you why we did not approve the request. If you do not agree with the decision, you may file an appeal. For more information refer to the grievance, appeal, and Medicaid Fair Hearing section on page 35. Prestige will make a decision as quickly as your health condition requires, but no later than 48 hours for an expedited request or 7 days for a standard request, unless we advise you that we need more time to gather information from your doctor. If that is the case, we may take an additional 2 business days for expedited requests or an additional 7 days for standard requests. We will notify you of the additional time needed within 5 business days of deciding we need more time for our review. If you disagree with this extension, you can file a grievance. If you need help, call Member Services at (TTY/TDD ). Hospital admissions When you are admitted to the hospital, prior approval is needed. In most cases, your doctor will handle this for you. Prestige will review the request for hospital admission within 24 hours of receiving the request. You should talk with your doctor if you have a question about hospital admissions. You can also call Member Services at (TTY/TDD ) to ask questions. In lieu of services If approved by the State, Prestige may cover certain services that would not typically be covered under the benefits of your health plan. These services are called in lieu of services. Before they are provided, you should be aware of when in lieu of services are being provided and should agree to these services instead of the services they are replacing. An example would be moving from the hospital to a skilled nursing facility (which is not a covered benefit under the plan) for a short period of time to help you get better after you have been in the hospital instead of staying in the hospital for a longer period of time. There are other examples of in lieu of services. You should talk with your PCP if you have a question. You can also call Member Services at (TTY/TDD ) to ask questions. Concurrent review A concurrent review is a review of your care while you are using certain services. Examples of these services are hospital stays, therapy services, and home health care. Prestige will begin this review when needed. Prestige Health Choice 17

19 Your Prestige benefits How your pharmacy benefits work Prescriptions Your provider will write a prescription for medicine to be filled by your pharmacist. Providers may refer to the preferred drug list (PDL) for the list of preferred formulary medicines. The PDL is available on the Prestige website. You must pick the medicine up at a pharmacy that is part of the Prestige network. You ll find a list of pharmacies in the provider directory at There is no cost to you for some covered prescriptions. Show your member ID card when you get your prescriptions. If you have any questions, call Pharmacy Member Services at if you need help. Prior authorization (pre-approval) Your provider may request a prescription for a medicine that is not preferred on the PDL and/or requires prior authorization. Your doctor will need to send us a prior authorization request form. We will review and let your doctor know our decision. If Prestige does not approve the medicine, you will get a letter that will tell you why. The letter will tell you how to submit an appeal if you want to do so. Over-the-counter expanded benefit Prestige covers several over-the-counter products under the over-the-counter expanded benefit. There is a limit to how many over-the-counter products you can get. Prestige allows each household a maximum of $50 per year. Visit for a list of some commonly approved products. Participating pharmacies You can use any of our participating pharmacies. If you need a list of pharmacies, call Member Services at (TTY/TDD ). You can also go to our website at Go to Members and then go to Find a doctor, medicine, pharmacy, or transportation provider. Pharmacy Member Services If you have questions, please call Pharmacy Member Services at Informed consent A parent or guardian must give informed consent for psychotropic medicines for children under 13 years old. Your PCP will ask you to sign a form. Please ask your PCP for help. How to get behavioral health services If you are having any of the following feelings or problems, you should contact a behavioral health care provider: Always feeling sad. Feeling hopeless. Feeling helpless. Feeling worthless. Having difficulty sleeping. Having a poor appetite. Weight loss. Loss of interest. Difficulty concentrating. Irritability. Constant pain like headaches, stomach aches, and back aches. 18 Prestige Health Choice

20 Your Prestige benefits You can get help finding a behavioral health provider by: Calling (TTY/TDD ). Looking at our provider directory. Going to our website at Someone is there to help you 24 hours a day, 7 days a week. You will be able to call a behavioral health care provider for an appointment. Please call so we can help you find the services you need. The Prestige access to care standards for behavioral health services and referrals are as follows: Urgent care will be seen within 1 day. Routine patient care will be scheduled within 1 week. Well-care visits will be scheduled within 1 month. You can also ask for a different behavioral health care coordinator/case manager or direct-service behavioral health care provider in our network if 1 is available. Remember: You do not need a referral from your PCP. You ll get an approval for services when you call. You may have to pay the bill if you see a provider without getting approval first or if you go to a provider who is not part of our network. Some of the services you may need for you or your family: Individual, family, or group therapy. Individual and family assessments. Day treatment for adults and children. Evaluations. Treatment planning. Case management. Therapeutic behavioral on-site services for children and teenagers. Emergencies and getting care away from home: If you think you are a danger to yourself or others, call 911 or go to the nearest ER. Once you are in a safe place, call your PCP if you can. Follow up with your doctor within 24 to 48 hours. When you have gotten emergency care out of the Prestige service area, Prestige will make plans to transfer you to an innetwork hospital or provider once you are stable. Care after an emergency Once you leave the hospital after a mental health emergency, you need to get care. We call this poststabilization service. This may help keep you from having another mental health emergency. Poststabilization services are given 24 hours a day, 7 days a week. These services do not need prior authorization. Behavioral health and substance use recovery Behavioral health services help members with difficulties with mental illness, drug use or alcohol use (substance use disorder, addictive disorders, or drug and alcohol use disorders). It is important to see a provider if you need help with these problems. Tell your PCP how you are feeling and ask about providers who can help. You can also call Member Services for mental health and substance use disorder services at (TTY/TDD ). Prestige Health Choice 19

21 Your Prestige benefits Healthy Behaviors programs Small decisions, like what we eat and how we deal with stress, have a big effect on our health. Earn rewards by completing the Healthy Behaviors Commitment Form for the weight loss, smoking cessation, or alcohol and substance use recovery programs. Please remember that rewards are non-transferable. If you leave Prestige for more than 180 days, you may not receive your reward. If you have questions or want to join any of these programs, please call Member Services at (TTY/TDD ). Weight loss Being overweight can raise your risk for many diseases. You can earn rewards in the weight loss program if your health care provider says you have a body mass index (BMI) of 35 or more. You will receive a gift card for visiting your provider and completing a Commitment Form. You can earn more gift cards by making an appointment to see a dietitian or nutritionist, or for following up with your provider. If you are in the weight loss program for 3 months and lower your BMI, you can earn another gift card! Smoking cessation We know that quitting smoking is not easy. With certified coaches, an online program and face-to-face classes, you can get the support to quit. When you sign up, you will get a gift card and free over-the-counter nicotine patches, lozenges, and gum. You can also earn a gift card for attending group sessions and seminars on quitting. When you finish the program and mail your Certificate of Completion to a Prestige Health Choice care manager, you will earn another gift card! Alcohol and substance use recovery You have a better chance of living without drugs and alcohol when you join a medically supported program. We can help you overcome alcohol or substance use with guidance from a care manager and your provider. Committing to quitting is a big step, and we will mail you a gift card for signing up! After you sign up, a care manager will help you join a local support group. We will mail you another gift card for being sober for 30 days and another gift card for being sober for 90 days. We want to help you stay sober, and will send you a gift card to help you celebrate 180 days of sobriety. The Healthy Behaviors Commitment Form can be found at or you can call Member Services at (TTY/TDD ). More healthy behaviors Each calendar year Prestige offers more Healthy Behaviors programs to reward you for completing health goals. You can ask your provider or visit our website to learn more about all of the available programs. You and your provider will work together on signing off on the completed program using the Healthy Behaviors Completion Form, which you can find at or by calling Member Services at (TTY/TDD ). Contact us to learn more We are here to help! If you would like to join, call Member Services at (TTY/ TDD ). Visit our website at for more details about each program s eligibility criteria. 20 Prestige Health Choice

22 Your Prestige benefits Physician incentive payments PCPs may receive extra payment for some services like immunizations. When PCPs meet other quality, service, and performance standards, they may get additional payments. Call Member Services for more information. Services Prestige does not cover Prestige doesn t cover some services. Always contact Prestige if you have questions about your benefits. These are the types of services not covered: Prestige may not cover all of your health care expenses. You may have to pay for services if you find out ahead of time that Prestige does not cover the services, or if you go to an out-of-network provider. It is important to check with your doctor or call Member Services at (TTY/TDD ) if you have any questions. There may be some services that Prestige does not cover, but might be covered under Medicaid. For additional assistance, you may call the Agency for Health Care Administration (AHCA) Medicaid Help Line at Services not medically necessary. Services provided by an out-of-network provider. We make exceptions for emergency services, family planning services, or services received when the requested service is not available through Prestige. You can see an out-of-network provider during your continuity of care time when you first join Prestige. See page 7 or more information on continuity of care. Infertility services. Elective abortions. Elective cosmetic surgery. Experimental or investigational drugs, procedures, or equipment. Services provided outside of the United States. Prestige Health Choice 21

23 Your Prestige benefits Aging and Disability Resource Centers (ADRCs) Area Agency on Aging offices: PSA 2: Bay, Calhoun, Franklin Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington counties PSA 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union counties PSA 5: Pasco and Pinellas counties PSA 6: Hardee, Highlands, Hillsborough, Manatee, and Polk counties PSA 7: Brevard, Orange, Osceola, and Seminole counties PSA 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota counties PSA 9: Martin, Okeechobee, Palm Beach, Indian River, and St. Lucie counties PSA 11: Miami-Dade and Monroe counties Area Agency on Aging for North Florida Local: Toll free: Elder Options Local: Toll free: Area Agency on Aging of Pasco-Pinellas Local: Toll free: Senior Connection Center Local: Toll free: Senior Resource Alliance Local: Toll free: Area Agency on Aging Southwest Florida Local: Toll free: Area Agency on Aging of Palm Beach/ Treasure Coast Local: Toll free: Alliance for Aging Local: Toll free: Prestige Health Choice

24 Your Prestige benefits We pay attention to your care Prestige s doctors and nurses check the services given to all members. They also make decisions about medically necessary care and services. Medical necessity Prestige will pay for care you need that is medically necessary. This means that a medical service is needed to find out what is wrong with you, relieve pain, or prevent you from getting sick. A provider must give treatment to you in a way that follows a good practice of medicine. A provider must also give the care to you in a place that is safe and effective. If you need help understanding this information, please call Member Services at (TTY/TDD ). As a Prestige member, you are not responsible to pay for medically necessary covered services supplied by a Florida Medicaid provider. If you receive a bill or statement, notify Member Services at (TTY/TDD ). Prestige does not: Reward health care providers for denying, limiting, or delaying benefits or health care services. Give incentives to staff or providers for making decisions about medically necessary services. Give rewards to provide less health care coverage and services. Prestige must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if Prestige does not cover a service or the service has a limit. As long as your child s services are medically necessary, services have: No dollar limits. No time limits, like hourly or daily limits. Your provider may need to ask Prestige for approval before giving your child the service. Call if you want to know how to ask for these services. Dedication to quality care Prestige has a mission to help people get care, stay well, and build healthy communities. We have a Quality Improvement (QI) program. This program looks for ways to improve your health and your family s health. We look for ways we can serve you better. The QI program: Looks for areas that need to be improved in medical and preventive services. Offers disease and health programs for you. Provides outreach to members and gives health education. Performs medical and service area studies when they are needed. Watches the quality of care and services given by Prestige providers, like medical, dental, vision, and pharmacy services. Creates programs for members with special health care needs. Works with providers to improve our services. Surveys members and providers and uses the answers to improve our services. Monitors itself to make sure it is working to improve services. If you would like more information about our quality improvement goals, activities, or outcomes, please call Member Services at (TTY/TDD ). PCPs, hospitals, and doctor groups receive payment for the services they give you. PCPs may get extra pay for some services, like immunizations. When PCPs meet other quality, service, or performance standards set by Prestige Health Choice 23

25 Your Prestige benefits Prestige, they may get extra payments. You can also get information about how Prestige rates on certain performance measures for some types of services. If you believe you or your family did not get quality care, please call Member Services. Prestige will look into your concern. For a copy of Prestige s preventive health and clinical practice guidelines, call Member Services at (TTY/TDD ). Evaluating new technology Prestige regularly reviews the latest procedures, drugs, devices, and methods to determine which will improve medical outcomes. Prestige uses criteria established to: Provide scientific analysis and opinions that advance the understanding of complex technology issues. Help in the development of medical policy. For more information, please call Member Services at Case management Prestige has a case management program to help you better understand and manage health problems. This is a service for members with special needs or who need help. Examples of special needs are long-term illnesses, injuries, and pregnancies. You do not need a referral from your PCP for these programs. The program coordinates services for adult and child members with short-term and/or long-term needs who have single problem issues or other conditions. Our goal is to help you know how to use your benefits and get the care you need with: Pharmacy. Equipment. Dental issues. Transportation. Getting appointments with providers. Behavioral health referrals. Community resources. Prestige Health Choice s Chronic Condition and Disease Management programs are included in our Complex Care management program for: Asthma. Diabetes. Heart disease, including high blood pressure. Chronic obstructive pulmonary disease (COPD). Our team will work with your PCP and assist with your health care needs. They will arrange home health visits and provide medical support items needed to help manage your health condition. They will also send you information about your condition. Licensed nurses or social workers called care managers support you over the phone. They also help arrange other services to help you quit smoking or find community support activities. Care managers help you better understand your condition and will work with you to develop a plan to help you address your special needs. They will help arrange health care and follow up by working with your PCP to ensure you get the care you need. If you have 1 of the health care conditions listed above, you could become a part of 1 of our special programs. If you want to be a part of 1 of these programs, or would like to refer a member, call the Rapid Response and Outreach Team at , Monday through Friday, 8 a.m. to 6:30 p.m. The Rapid Response and Outreach Team The Rapid Response and Outreach Team helps members with health-related issues. All Prestige members can call the Rapid Response and Outreach Team at for help with their health care. We are available to help with urgent issues. 24 Prestige Health Choice

26 Your Prestige benefits We also provide support in figuring out health care services. Sometimes we all need a little help with our medical needs. The Rapid Response and Outreach Team will answer your questions and help solve problems. For example, we help schedule appointments. We can find transportation options. We can also remind you when important health tests are due. The Rapid Response and Outreach Team has a network of community resources, which provide housing support, utility assistance, and a variety of other services. We help you with these issues so you can focus on caring for your loved ones and your health. Do you have a question about your health plan? Do you need to know how to take a medicine? Do you need a broken wheelchair or other health equipment fixed? The Rapid Response and Outreach Team can help you get answers to your questions. We can help find the right services to support you and your family. You can reach the Rapid Response and Outreach Team at from 8 a.m. until 6:30 p.m., Monday Friday. You can always call Member Services at (TTY/TDD ), 24 hours a day, 7 days a week. Your family and Prestige Child Health Check-Up (CHCUP) Program Prestige has a CHCUP program for members younger than 21 years old. The CHCUP program helps you get the health care your child needs. This can help prevent or find problems as early as possible so your child can stay healthy. Please call Member Services at (TTY/TDD ). We can help you get the health care your child needs and help you select a PCP for your child. You can take your child to a pediatrician, family practice doctor, or other Prestige network providers. The provider you choose can be your child s PCP. The PCP will make sure your child gets needed checkups and immunizations, answer your medical questions, and help your child stay healthy. Once you become a Prestige member, please call your child s PCP to make your first appointment. Prestige wants parents to make sure their children are getting regular medical checkups. You do not need a referral for these visits. For more information about the screenings and assessments that are recommended from infancy through adolescence, please refer to the Recommendations for Preventive Pediatric Health Care Periodicity Schedule at Why should my child have wellness or checkup visits? All Prestige members need to have regular wellness visits with their PCP to stay healthy. Babies need to see their PCP 7 times by the time they are 12 months old and more times if they are sick. If your child has special health needs such as asthma or diabetes, we can help your child get checkups, tests, and shots. Prestige Health Choice 25

27 Your Prestige benefits How often should my child have a CHCUP? Your child s first well-child visit will happen in the hospital right after your baby is born. For the next visits, you must take your baby to his or her PCP s office. You must set up a well-child visit with the doctor when the baby is: 1 month old. 2, 3, 6, 9, 12, 15, 18, and 24 months old. 1 time per year from 2 to 20 years old. Be sure to make these appointments. Please take your child to his or her PCP for all appointments. What areas of my child s health will be checked? A review of your child s physical and mental growth. A complete physical exam. Nutritional and developmental review. Vision, hearing, and dental tests (screenings). Lab tests (including blood lead testing for children ages 12 and 24 months). Immunizations these are important to help the body fight disease. Children must have all of their shots before starting school. Health education and help with preventive care. Diagnosis and treatment. Referral and follow up, as needed. Will my provider charge me for my child s CHCUP medical visit? There is no charge for CHCUP visits. How can I make sure my child gets a CHCUP medical visit? Call your child s PCP office to make an appointment. When you call for an appointment, tell the PCP s office that your child is a Prestige member. If you need help or have problems, call Member Services at (TTY/TDD ). If you need transportation to the PCP s office, call Member Services at (TTY/TDD ) to help you arrange transportation to medical appointments. Blood lead testing Your child s PCP should test your child for lead poisoning. Many items such as children s toys, jewelry, and clothes are being found to have high levels of lead. Your child needs a blood lead test at 12 months and 24 months. Your child should get the test between 36 and 72 months if your child has never been tested before. Your child s doctor will take a blood sample by pricking the finger or taking blood from a vein. This test will tell if your child has harmful lead in his or her blood. Vision screening Your child s PCP should check your child s vision at every well-child visit. Hearing screening Your child s PCP should check your child s hearing at every well-child visit. Dental screening Your child should have his or her teeth and gums checked by his or her PCP as a part of regular well-child visits. At age 3, your child should begin seeing a dentist every 6 months. Immunizations (shots) It is important for your child to get his or her shots on time. Take your child to the doctor when his or her PCP says a shot is needed. Women s services Well-woman visits are important for good health for adult women. Annual mammograms and cervical cancer screenings (Pap tests) are important steps in maintaining a woman s health. Contact your PCP 26 Prestige Health Choice

28 Your Prestige benefits for help to get well-woman visits, tests, and family planning services. Choosing an OB/GYN Female members can see a Prestige obstetrician and/ or gynecologist (OB/GYN) for OB/GYN health needs. These services include well-woman visits, prenatal care (visits while you are pregnant), care for any female medical condition, family planning, and referral to a special doctor within the network. You do not need a referral from your PCP to see your OB/GYN. If you do not want to go to an OB/GYN, your PCP may be able to treat you for your OB/GYN health needs. Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. You will find a list of network OB/GYNs in the Prestige provider directory. You will need to choose a PCP for your baby in your last 3 months (trimester) of pregnancy. The third trimester begins in week 28 and lasts through the end of your pregnancy. Special care for pregnant members The Bright Start program is for all pregnant members. Early and complete health care before your child s birth is the key to having a healthy baby! Bright Start helps moms-to-be make healthy choices for themselves and their unborn babies. Who can be a member of Bright Start? Any Prestige member who is pregnant can be a member of Bright Start. You do not need a referral from your provider to become a member of the Bright Start program. If you, a friend, or family member would While you are pregnant, your OB/GYN can become your PCP. If you need help picking an OB/GYN, call Member Services. If you think you are pregnant If you think you are pregnant, call your PCP or OB/ GYN right away. It is very important you see your PCP or OB/GYN when you are pregnant. We call this prenatal care. It helps you and your baby stay healthy. You do not need a referral to see your PCP or OB/ GYN. If you do not have an OB/GYN, contact Member Services at (TTY/TDD ) for help picking an OB/GYN. If you are pregnant, remember to call the Florida DCF toll free at You will need to update your information with them. You will need to call Member Services at (TTY/TDD ) when you find out you are pregnant. This will help your baby get Prestige benefits when he or she is born. Prestige Health Choice 27

29 Your Prestige benefits like more information about Bright Start or would like to make a referral, call Does Bright Start cost anything? Bright Start is free of charge to Prestige members. How does Prestige help Bright Start members? Your health care provider will decide if your pregnancy is low risk or high risk. If the pregnancy is low risk, you will talk to a Bright Start outreach coordinator about your needs, services, and classes you may attend. The outreach coordinator will also help you choose a Prestige OB/ GYN and a PCP for your baby. They will also mail information to you during your pregnancy. After your baby is born, the Bright Start outreach coordinator will talk with you to help you get health services for your baby. What if my pregnancy is high risk? You might be at high risk if: You are under 18 years old. You had a problem pregnancy in the past. Your doctor tells you that your pregnancy is high risk. Each Bright Start high-risk member works with a special nurse. The nurse helps you get the care you need. The nurse will give you information about your needs. The nurse will work with you to get special services you may need, including social work, special diet, referrals to specialists, home health services, or help from local agencies. What about Women, Infants, and Children (WIC)? When you are pregnant you will need to see your PCP or OB/GYN at least: Every 4 weeks for the first 32 weeks. Every 2 weeks from week 32 until week 36. Weekly from week 36 until delivery. Your PCP or OB/GYN may want to see you more often based on your health needs. Having a baby When you deliver your baby, you and the baby may stay in the hospital at least: 48 hours after a vaginal delivery. 96 hours after a cesarean section (C-section). You may stay in the hospital less time if your PCP or OB/GYN and the baby s doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby, remember to call Member Services as soon as you can to tell us you had your baby. We will need to get information about your baby, too. You may have already picked a PCP for your baby before he or she was born. If not, we can help you pick a PCP for him or her. You must also call your Florida DCF caseworker when you have your baby. Newborn and child circumcisions Circumcisions are covered for newborns during inpatient delivery stays and for 90 days after birth in the physician s office. Place of service, other than the physician s office, is excluded after initial hospital stay. No prior authorization is required. If you are pregnant, you need to take good care of your health. You may be able to get healthy food from the WIC program. You can call Member Services at (TTY/TDD ) for help with a referral to a WIC provider. 28 Prestige Health Choice

30 Your rights and responsibilities Your responsibilities as a Prestige member Keeping yourself and your family healthy can be easy. Here is the list of what you need to do. 1. Read your member handbook. Call Member Services if you have questions. 2. Choose your new PCP when you get your welcome kit. Help your new PCP care for you and your family. Fill out all information sheets carefully. Help your PCP get your records from your previous doctor. Give, as much as possible, information that Prestige needs to process claims, and information providers need to give care. 3. Help your providers manage your care. Understand your health problems and take part in developing treatment goals. Follow plans and instructions for care from your providers. If your care plan does not work, tell your provider. He or she wants you to feel better. He or she will adjust your care plan to make it work. 4. Keep your appointments for all regular care. Examples are CHCUPs, family planning appointments, and health screenings. 5. Get a referral from your PCP before you see a specialist or out-of-network provider or go to the hospital. Only go to the hospitals or specialists your PCP recommends. If you visit an out-of-network provider, you will need to get prior authorization by calling If your member ID card is ever lost or stolen, call Member Services. 7. Present your member ID card any time you receive medical services from a doctor, hospital, clinic, or pharmacy. 8. Call your PCP when you feel sick. Do not wait. Go to the nearest ER if you feel your life is in danger. 9. Call Member Services if any information about you or your family changes, including your mailing and home address. This helps us avoid most problems. If your address has changed, please log in to your My ACCESS account and update your address. Log on to the My ACCESS system at dcf-access.dcf.state.fl.us/access/index.do. You can also contact the ACCESS Customer Call Center toll free at You must also contact the Social Security Administration (SSA) toll free at or visit the SSA website at Be kind to everyone involved in your care. Be on time for your appointments. Call the doctor s office if you cannot keep your appointment. Patient responsibility for facility-based services Patient responsibility is the cost of Medicaid facilitybased services not paid for by the Medicaid program and is the amount a member must contribute toward the cost of their care. This amount is determined by the Department of Children and Families and is based on income and type of placement. Members are required to pay this patient responsibility as determined by the Department of Children and Families. Your rights and protections as a Prestige member Prestige and its network of PCPs and other providers of services do not discriminate against members based on race, national origin, sex, religion, disability, age, sexual orientation, or any other basis prohibited by law. Prestige is committed to complying with all applicable requirements under federal and state law and regulations pertaining to member privacy and confidentiality rights. As a member, you have the right to: 1. Getting information about: Prestige and its health care providers. Prestige Health Choice 29

31 Your rights and responsibilities Your rights and responsibilities. Your benefits and services. The cost of health care services and any required cost sharing. 2. Have Prestige and its health care providers treat you with dignity and respect. 3. Talk with your health care provider about: Treatment plans. Information on available treatment options and alternatives, given in a way you understand. The kinds of care you can choose to meet your medical needs, regardless of cost or benefit coverage. 4. Receiving care that is at least equal to service offered by similar health plans. 5. Receiving detailed information about emergency and after-hours options. Some details include: Emergency services do not require prior approval. You can use any hospital for emergency care. We give you lists of emergency conditions. You will learn what to do after you have received emergency care. 6. Be a part of decisions about your health care, including the right to refuse treatment. Your decision to do so will not negatively affect the way Prestige, its health care providers, or the state treat you. 7. Being free from any form of limitations used to discipline, for convenience, or in retaliation. 8. Talking to your PCP about family planning. These services are available without prior approval. Family planning services are available from any Medicaid provider. 9. Being told about free translation services. We will arrange support for any language you speak. You ll be told about free services for members with vision and hearing loss. You ll receive the communication services you need to help make choices about your care. We can teach you more. Please call Member Services at (TTY/TDD ). 10. Accessing the Notice of Privacy Practices. This tells you when, why, and with whom we must sometimes share your protected health information (PHI). 11. Seeing your PHI. 12. Having your privacy protected in accordance with Health Insurance Portability and Accountability Act (HIPAA) requirements. 13. Seeing a list of the people who have asked to see your PHI. 14. Getting a copy of your PHI in our records. 15. Requesting a copy of your medical records and asking that your PHI be updated if it is not correct. 16. Receiving information about the grievance, appeal, and Medicaid Fair Hearing process. We will arrange support for any language you speak. 17. Having health care services provided in accordance with both state and federal regulations. 18. Getting yearly updates about the disenrollment process. 19. Receiving updates on major changes in your benefits. You ll be notified at least 30 days in advance. 20. Be given an opportunity to provide suggestions for changes to Prestige s rights and responsibilities policy. 30 Prestige Health Choice

32 Your rights and responsibilities 21. Voice complaints about and/or appeal decisions made by Prestige and its health care providers. Call Member Services at (TTY/TDD ). We will arrange support for any language you speak. Protecting your privacy Your privacy is important to us. That s why we take great care to make sure we use your personal information correctly and keep it safe. This information comes from you, your PCP, hospitals, and other health care providers. This information is called protected health information or PHI and can be oral, written, or electronic. There are certain ways we use your health information, keep it safe, and share it with others. In general, we may use it to: Provide treatment. Provide benefits. Help your health team treat you and receive payment. Coordinate payment to other insurance companies. Evaluate and improve our services. We may also use and share your health information based on the law or Prestige policies. If you have questions about how we keep your information private, refer to the Notice of Privacy Practices included in this welcome kit. You can also call Member Services at (TTY/TDD ). Fraud and abuse Prestige is committed to quality. But there may be times when you see fraud or abuse. Some examples of fraud and abuse by a health care provider are: Billing or charging you for services that Medicaid covers (other than copays). Offering you gifts or money to get treatment or services that you do not need. Offering you free services, equipment, or supplies in exchange for using your member ID number. Giving you treatment or services that you do not need. Physical, mental, or sexual abuse by medical staff. Some examples of fraud and abuse by a member are: Members selling or lending their member ID cards to other people. Members abusing their benefits by seeking drugs or services that are not medically necessary. To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll free at or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at apps.ahca.myflorida.com/inspectorgeneral/ fraud_complaintform.aspx. If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General s Fraud Rewards Program (toll free or ). The reward may be up to 25 % of the amount recovered, or a maximum of $500,000 per case (Section , Florida Statutes). You can talk to the Attorney General s Office about keeping your identity confidential and protected. You can also report fraud and abuse to Prestige. The Prestige Fraud Hotline toll-free number is Prestige Health Choice 31

33 More about Prestige Other abuse Prestige cares about you. If you are being abused, neglected, or exploited, please call the toll-free hotline, ABUSE. There is no reason for physical, mental, or sexual abuse. Advance directives People who are 18 years old or older often make important choices about their health. State law lets you accept or refuse medical or surgical treatment. The law lets you pick someone to choose your care if you cannot. You can also say you want to make an organ donation. The form that states your choices is called an advance directive. If there are any changes in the law, we will let you know within 90 days. The best way to make sure your advance directive is followed is to write it down. You can download a form from www. floridahealthfinder.gov/reports-guides/advancedirectives.aspx. Your PCP will help you create an advance directive. Make sure you keep a copy and give a copy to your PCP. Complaints about non-compliance with advance directive laws and regulations may be filed with the State s AHCA complaint hotline at Living will A living will is a type of advance directive. You should always get help writing a living will. It needs to be very clear. Keep 1 copy in a safe place. Give the other copy to your PCP. You can download a form from www. floridahealthfinder.gov/reports-guides/advancedirectives.aspx. Choosing a health care surrogate Sometimes we need help making choices. Often we need that help when we are very sick. A health care surrogate is someone you pick to make health care choices for you. They can only make choices for you during the time you are too sick to make your own choices. You should pick someone you trust. Talk with them about your wishes. Make sure they understand what you want. Always get help writing a health care surrogate agreement. Be sure to include clear limits in the surrogate s authority. If you need help appointing a health care surrogate visit gov/reports-guides/advance-directives.aspx. If you feel there is a problem with your advance directive, you can file a complaint with the state. You can find more information at You can get help making an advance directive. Talk to your PCP if you need help completing an advance directive. The Personal Representative Request Form included in the welcome kit is not a designation of health care surrogate. This form is optional and for your health plan. This form is for tracking purposes only and is not of transferable use for another provider. Disenrollment If you are a mandatory enrollee and you want to change plans after the initial 120-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change managed care plans: 1. The enrollee does not live in a region where the Prestige is authorized to provide services, as indicated in the Florida Medicaid Management Information System (FMMIS). 2. The provider is no longer with Prestige. 32 Prestige Health Choice

34 More about Prestige 3. The enrollee is excluded from enrollment. 4. A substantiated marketing violation has occurred by Prestige. 5. The enrollee is prevented from participating in the development of his/her treatment plan/plan of care. 6. The enrollee has an active relationship with a provider who is not on Prestige s panel, but is on the panel of another managed care plan. Active relationship is defined as having received services from the provider within 6 months preceding the disenrollment request. 7. The enrollee is in the wrong managed care plan as determined by the Agency. 8. Prestige no longer participates in the region. 9. The state has imposed intermediate sanctions upon Prestige, as specified in 42 CFR (a)(4). 10. The enrollee needs related services to be performed concurrently, but not all related services are available within the Prestige network, or the enrollee s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk. 11. Prestige does not, because of moral or religious objections, cover the service the enrollee seeks. 12. The enrollee missed open enrollment due to a temporary loss of eligibility. 13. Other reasons per 42 CFR (d)(2) and s (2), F.S., including, but not limited to: poor quality of care, lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee s health care needs, or fraudulent enrollment. If you think you have a good cause reason for disenrollment, call a Medicaid Choice Counselor toll free at Voluntary enrollees may disenroll from the plan at any time. Some Medicaid recipients may change managed care plans whenever they choose, for any reason. To find out if you may change plans, call the Enrollment Broker at (TTY/TDD ). Reasons why you may be disenrolled You can lose your Prestige benefits (be disenrolled from Prestige) if: 1. You let someone else use your member ID card. 2. You act violent or threaten someone at Prestige. 3. You are no longer eligible for Medicaid. 4. You are admitted to a long-term care facility or hospice or go to prison. 5. You move out of the service area. Grievances, appeals, and Medicaid fair hearings Prestige is here to help you. If you are unhappy with the plan or with the care you have received, you can call Member Services at (TTY/TDD ) for help. Complaints You have the right to file a complaint with Prestige. If we receive a complaint, we will try to resolve it by the end of the next business day. If we cannot resolve your complaint, it will be moved into the Prestige grievance system within 24 hours. Prestige Health Choice 33

35 More about Prestige Once in the grievance system, Prestige will determine if your complaint is a grievance or an appeal. A grievance is when you are unhappy with our plan or 1 of our providers. An appeal is when you are unhappy about a decision made by Prestige. This is usually if Prestige decides to deny, limit, reduce, suspend, or stop any service. If you want to appeal, Prestige will review the decision again. Grievances If you want to file a grievance, call Member Services at (TTY/TDD ), 24 hours a day, 7 days a week. We will help you understand the process and arrange support for any language you speak. As an enrollee, you are able to file a grievance at any time. You can also write a letter to tell us about your grievance. Anybody you trust can help you write the letter. Our address is: Prestige Health Choice P.O. Box 7368 London, KY Prestige will mail you a letter within 5 business days to let you know we have received your grievance. You can ask us to extend the review time for your grievance up to 14 days. Call Member Services at (TTY/TDD ) to let us know. If Prestige decides we need more time to review your grievance, we will let you know in writing within 2 calendar days. We will make a decision regarding your grievance within the next 14 days. We will tell you the reason why we need more time to review your grievance. While we review your grievance, we will do the following: Allow you to give us any information that you feel will be helpful to us in making a decision. Call you if we need more information. Let you review any medical and case records and other material being reviewed. Explain to you all time frames related to your grievance. Prestige will make a decision on your grievance within 90 days from the day we receive it. We will mail you a notice (letter) with the following: Our decision. The date the decision was made. Appeals If you are unhappy with a decision made by Prestige, you can ask us to look at the decision again. This is an appeal. You must file your appeal within 60 days from the date on the notice (letter) you receive. You may file your appeal by phone or in writing. If you file your appeal by phone, you must send us a written notice within 10 days of your phone call. We will use the date of your phone call as the start date for your appeal. Our address is: Prestige Health Choice P.O. Box 7368 London, KY Our fax is You can continue receiving services while we review your appeal. You may have to pay for services if your appeal is denied. 34 Prestige Health Choice

36 More about Prestige You can ask for us to extend the review time for your appeal by up to 14 days. Call Member Services at (TTY/TDD ) to let us know. If Prestige decides we need more time to review your appeal, we will let you know in writing within 2 calendar days. We will tell you the reason why we need to extend the review time. While we review your appeal, we will do the following: Allow you to give us any information that you feel will be helpful to us in making a decision. Call you if we need more information. Let you review any medical and case records and other material being reviewed. Explain to you all time frames related to your appeal. We will make a decision on your appeal within 30 days from the day we receive it. If you need the decision faster, you can ask for an expedited (fast) appeal. See below for details. We will mail you a notice (letter) with the following: Our decision. The date the decision was made. How to request a Medicaid Fair Hearing. How to appeal our decision through the Subscriber Assistance Program (SAP). Expedited appeals An expedited (fast) appeal is what you request when you or your provider thinks your health is at risk, and a decision needs to be made in less than 30 days. You or your provider may ask for an expedited appeal by calling Prestige will start to review your expedited appeal the day it is received. We will make a decision within 72 hours of receiving your request. We will attempt to notify you of the decision by phone first. We will also mail you a notice about the decision. If you ask for an appeal to be expedited, and we decide that this is not needed, the appeal will be reviewed within the standard appeal time frame (30 days). You will be informed by phone the same day we decide an expedited appeal is not needed. You will also receive a written letter within 2 days if the time frame for your appeal has changed. Appealing to the Subscriber Assistance Program If you have completed the Prestige appeal process and you are still unhappy, you can appeal to the Subscriber Assistance Program (SAP). The SAP is a committee run by the state of Florida. You must complete the appeal process with Prestige before you can submit your appeal to the SAP. You must submit your appeal to the SAP within 1 year after getting the decision notice (letter) from Prestige. If you have already gone through a Medicaid Fair Hearing, you cannot appeal to the SAP. You can submit your appeal with the SAP by writing to: Agency for Health Care Administration Subscriber Assistance Program Building 3, MS # Mahan Drive Tallahassee, Florida You can also call the SAP at or Medicaid Fair Hearing You can ask for a Medicaid Fair Hearing instead of filing with the SAP. Please note that Medikids members are not eligible to participate in the Medicaid Fair Hearing process. An independent officer at the Agency for Healthcare Administration conducts a Medicaid Fair Hearing. With your written approval, you can choose someone to speak for you at the Medicaid Fair Hearing. The hearing officer will make a decision based Prestige Health Choice 35

37 More about Prestige on rules and regulations, the facts produced during the hearing, and post-hearing submissions. A decision from a Medicaid Fair Hearing is final and cannot be appealed. You can ask for a Medicaid Fair Hearing if you have gone through the Prestige appeal process. You must request a fair hearing within 120 days from the date on the notice (letter) of resolution for your appeal. You can request a Medicaid Fair Hearing by writing to: Agency for Health Care Administration Medicaid Hearing Unit P.O. Box Ft. Myers, FL You can also request a Medicaid Fair Hearing by: Calling Faxing ing MedicaidHearingUnit@ahca.myflorida.com 36 Prestige Health Choice

38 Important phone numbers and information My Prestige ID number: Other family members ID numbers: My PCP/medical home: My child s PCP/medical home: My dentist: My child s dentist: My Prestige care manager: My child s Prestige care manager: Prestige Member Services: (TTY/TDD ) Prestige Nurse Call Line: Prestige Behavioral Health Member Services: , option 1 Prestige Rapid Response and Outreach Team: Prestige Fraud Hotline: Prestige Pharmacy Member Services: Non-emergency transportation Enrollment Services/Medicaid Choice Counseling: Florida s Department of Children and Families: Agency for Health Care Administration Medicaid Helpline or Agency for Health Care Administration Facility Complaint Call Center , option 1 To report a complaint against a health care facility, please call toll free (press option 1), or visit ahca.myflorida.com/contact/call_center.shtml. If your concerns represent a potential regulatory violation, the Agency will conduct a complaint inspection. Get the latest updates from our website and the member portal. Sign up. Log on. Stay connected at Prestige Health Choice 37

39 Your notes 38 Prestige Health Choice

40 Non-discrimination notice and language services Discrimination is against the law Prestige Health Choice complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Prestige does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Prestige: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters. - Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: - Qualified interpreters. - Information written in other languages. If you need these services, contact Prestige at (TTY ). We are available 24-hours, 7 days a week. If you believe that Prestige has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Fax: You can file a grievance by mail, fax, or phone. If you need help filing a grievance, Prestige Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at: La discriminación está en contra de la ley Prestige Health Choice cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, origen nacional, edad, discapacidad o sexo. Prestige no excluye a las personas ni las trata de modo diferente debido a su raza, color, origen nacional, edad, discapacidad o sexo. Prestige: Proporciona a las personas con discapacidades, para que puedan comunicarse con nosotros eficazmente, asistencia y servicios gratuitos, tales como: - Intérpretes calificados del lenguaje de señas. - Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). Proporciona servicios sin cargo a personas cuyo idioma principal no es el inglés, por ejemplo: - Intérpretes calificados. - Información escrita en otros idiomas. Si necesita estos servicios, llame a Prestige al (TTY ). Estamos disponibles las 24 horas del día, los 7 días de la semana. Si cree que Prestige no ha provisto estos servicios o ha discriminado de otra manera en función de raza, color, origen nacional, edad, discapacidad o sexo, usted puede presentar una queja formal dirigida a: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Fax: Puede presentar una queja formal por correo postal, fax o teléfono. Si necesita ayuda para presentar una queja formal, Servicios al Miembro de Prestige está disponible para ayudarlo. También puede presentar una queja relativa a los derechos civiles ante el Departamento de Salud y Servicios Humanos de los EE.UU., Oficina de Derechos Civiles (en inglés, U.S. Department of Health and Human Services, Office for Civil Rights) de manera electrónica a través del Portal de Quejas sobre Derechos Civiles, disponible en portal/lobby.jsf, o por correo postal o teléfono a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Los formularios de quejas están disponibles en: Prestige Health Choice 39

41 Non-discrimination notice and language services Zak diskriminasyon pa ann amoni ak lalwa Prestige Health Choice dakò ak lwa federal sou dwa sivil yo epi li pa fè diskriminasyon sou baz ras, koulè, peyi kote w soti, laj, andikap oswa sèks ou. Prestige pa mete sou kote oswa trete moun lòt jan akoz ras, koulè, peyi kote w soti, laj, andikap oswa sèks ou. Prestige: Bay moun ki gen andikap asistans ak sèvis gratis pou kominike fasilman ak nou, tankou: - Entèprèt konpetan nan lang siy. - Enfòmasyon sou lòt fòma (gwo karaktè, odyo, fòma elektwonik aksesib, lòt fòma ankò). Bay moun ki pa fò nan anglè sèvis lang gratis, tankou: - Entèprèt konpetan. - Enfòmasyon ki ekri nan lòt lang. Si w ta bezwen youn nan asistans sa yo, kontakte Prestige nan (TTY ). Nou disponib 7 jou sou 7 epi 24 sou 24. Si w ta konstate Prestige neglije bay sèvis sa yo oswa fè diskriminasyon kèlkonk sou baz ras, koulè, peyi kote w soti, laj, andikap oswa sèks, ou ka depoze yon doleyans nan: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Faks: Ou ka depoze yon doleyans pa mwayen imèl, faks, oswa telefòn. Si w gen difilte pou w depoze yon doleyans, yon Manm nan Sèvis Prestige la ap kontan ede w. Ou ka pote yon plent sou dwa sivil bay Depatman Sante ak Sèvis Dwa Moun Etazini an ak Biwo Dwa Sivil la pa mwayen elektwonik, ou ka fè sa sou Paj pou Plent Biwo pou Dwa Sivil la nan lobby.jsf, oswa pa mwayen kourye oswa telefòn nan: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Fòmilè pou plent yo disponib nan: Multi-language interpreter services English: ATTENTION: If you speak English, language assistance services, free of charge [at no cost], are available to you. Call Spanish: ATENCIÓN: Si usted habla español, tiene a su disposición servicios de asistencia lingüística de forma gratuita [sin costo]. Llame al Haitian Creole: ATANSYON: Si w pale Kreyòl ayisyen, ou kapab jwenn sèvis ki gratis [san sa pa koute w anyen] pou ede w nan lang pa w. Rele nan Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان )بدون تكلفة(. اتصل برقم Chinese Mandarin: 注意 : 如果您说中文普通话 / 国语, 我们可为您提供免费语言援助服务 [ 无需付费 ] 请致电: Chinese Cantonese: 注意 : 如果您使用粵語, 您可以免費獲得語言援助服務 [ 無需付費 ] 請致電 Syriac: Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí [không mất tiền] dành cho bạn. Gọi số Albanian: VINI RE: Nëse flisni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë [pa asnjë shpenzim nga ana juaj]. Telefononi në Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를비용부담없이 [ 무료로 ] 이용하실수있습니다 번으로전화해주십시오. Bengali: লক ষ য কর ন আপনন যন ব ল য় কথ বললন ত হলল নবন ম ললষ য [নন খরচ য়] ভ ষ সহ য়ত পনরলষব প লবন এর জনষ য নম বলর ফ ন কর ন Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej [bez żadnych kosztów] pomocy językowej. Zadzwoń pod numer German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen gebührenfrei (kostenlos) sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: French: ATTENTION : si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement [sans coût]. Appelez le Japanese: 注意事項 : 日本語を話される場合 言語支援フリーサービス ( 無料 ) をご利用いただけます まで お電話にてご連絡ください Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные [на безвозмездной основе] услуги перевода. Звоните Serbo-Croatian: PAŽNJA: Ako govorite srpsko-hrvatski, na raspolaganju su vam besplatne usluge tumača [bez naplate]. Nazovite Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari mong mapakinabangan ang libreng [walang bayad] language assistance service (pag gabay sa wikang Tagalog). Tumawag sa Prestige Health Choice

42 PRES M1001_1701 This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7.

43 Welcome to Prestige Health Choice. We are happy to have you as a member. Prestige Health Choice members deserve a health care plan that is easy to use and understand. About Prestige Health Choice Dedicated to quality health care in your community. Committed to offering programs that increase awareness of health and wellness. Offers special programs for members with chronic conditions such as asthma, diabetes, and heart disease. We want to help you and your family members be healthy. In your packet you will find the member handbook, which tells you about Prestige Health Choice benefits and services, including: Your primary care provider (PCP). How to change PCPs or health plans. Covered services. Expanded benefits. Special health programs. Important phone numbers. Member rights and responsibilities. Appeals and grievance process. Loss of eligibility process. Also included is: Member Contact Form. Authorization for Disclosure of Health Information. Initial Health Screening Questionnaire. Personal Representative Request Form. Notice of Privacy Practices. Please to fill out the following forms right away. You can use the stamped envelope provided to return these forms: Authorization for Disclosure of Health Information Form. Initial Health Screening Questionnaire. Personal Representative Request Form (optional). There is no need to fill out the Member Contact Form unless your information has changed. If you complete this form, return it with the other forms in the same stamped envelope. All other materials are for you to keep. Member Services will call you in the next 90 days. This call is important. It helps us find out about your health and each family member enrolled with Prestige. It is especially important for your children so we make certain you are able to take them to see their PCPs for their yearly checkups. Please call Member Services if you need help with: Understanding any of our services or benefits. Getting services if you are hearing- or vision-impaired. Changing PCPs or going to another plan. Language assistance for members to discuss utilization management issues. Call Member Services at (TTY/TDD ) with any questions. For a list of Prestige providers, go to our website at Thank you, Prestige Member Services

44 PRES This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7.

45 Zika Virus and Pregnancy Zika virus is a disease you can get from being bitten by a mosquito carrying the virus or from having unprotected sex with an infected person. Zika virus may make you feel like you have the flu. The most common symptoms are fever, rash, joint aches, pink eye, and headache. It can take up to 2 weeks for a person with Zika virus to notice any symptoms. A blood test is the only way to confirm that someone has the virus. Not all mosquitoes carry Zika virus. A pregnant woman who has Zika virus can spread the virus to her baby. Serious birth defects have been reported in babies born to women who had Zika virus during pregnancy: Microcephaly (abnormal smallness of the head associated with incomplete brain development). Other severe brain defects. Eye defects. Hearing loss. Impaired growth. If you are planning to have a baby and you have been diagnosed with Zika virus or have symptoms of Zika virus, the Centers for Disease Control and Prevention (CDC) recommends: You call your health care provider. Women wait at least 8 weeks after their symptoms first appeared before trying to get pregnant. Men wait at least 6 months after their symptoms first appeared to have unprotected sex. The Zika virus lives longer in semen than in blood. Both men and women who have been exposed to Zika virus, but have not had the Zika infection, wait at least 8 weeks before having unprotected sex. Women use contraception to avoid Zika-related pregnancy complications. If you are pregnant and have symptoms or have been exposed to the Zika virus, call your health care provider right away.

46 Zika Virus and Pregnancy More cases of Zika virus are showing up in the United States. That s why everyone needs to know about the potential danger. If you are already pregnant: Avoid or delay traveling to areas where there is active Zika virus transmission. Protect yourself from mosquito bites. Use insect repellent or wear long-sleeved shirts and long pants. Prevent transmission if your partner has been exposed by using condoms or not having sex during pregnancy. Prestige Health Choice covers several over-the-counter (OTC) insect repellent products. See the table below for products that are included in our expanded OTC benefits list. Product name Ounces UPC OFF! Family Care 2.5 oz OFF! Deep Woods 4 oz OFF! Deep Woods 6 oz OFF! Active 6 oz Cutter Skinsations 6 oz Cutter Backwoods 6 oz Repel Insect Sportsmen 6.5 oz Repel Sportsmen Max Formula 6.5 oz The coverage of OTC medicine is limited to a maximum of $50 per year, per household. Talk to your health care provider if you have any questions about your health. If you are pregnant, you can also call Bright Start, the Prestige Health Choice maternity program, at , Monday through Friday, 8 a.m. 5 p.m. Visit for the most up-to-date information about the Zika virus. EWM This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7.

47 We will help you find a provider near you. RE: Provider Directory Dear Member: We are pleased that you have chosen Prestige Health Choice as your health plan. We are committed to making sure you get the care you need. As a member, you have access to our network of doctors, hospitals, pharmacies, and other providers. Here are the ways you can find a Prestige provider near you: Online Searchable Provider Directory If you would like to find information about Prestige providers online, visit and click on Find a doctor, medicine, pharmacy, or transportation under the Member tab to begin your search. Printed Provider Directory If you would like to receive a printed paper copy of the current Provider Directory, you can call Member Services at (TTY/TDD ) and we will send one to you. We re here to help you. If you have questions or need help finding a Prestige provider, call Member Services at any time. The toll-free number is Thank you for choosing Prestige Health Choice. Sincerely, Prestige Member Services This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. ML1201_1606

48 Please read this letter! It is important. RE: Transfer medical records to your new primary care provider (PCP) Dear Member: If you plan to change your primary care provider (PCP), Prestige Health Choice can help you ask for your medical records from your old PCP. You need to approve the release of your medical records from your old PCP to your new one. You will find an Authorization for Disclosure of Health Information Form in your welcome package. This form gives your old PCP permission to send your records to your new PCP. Please read and sign the form. Take the form to your old PCP. He or she will send your medical records to your new PCP. Your new PCP will then have access to your medical records. If you have any questions, call Member Services at any time. The toll-free number is Thank you for choosing Prestige Health Choice. Sincerely, Prestige Member Services This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. ML1005_1701

49 Authorization for Disclosure of Health Information Please print clearly in blue or black ink. This form is used to release your protected health information (PHI) as required by federal and state privacy laws. PHI is information about you that may identify you and relates to your past, present, or future physical or mental health or condition and related health services. This includes all information about your health evaluations, diagnoses, and treatments, and/or prescription records. Your authorization allows Prestige Health Choice (your insurance carrier) to release your PHI to a person or organization you choose. You can revoke this authorization at any time by submitting a request in writing to Prestige Health Choice. Revoking this authorization will not affect any action taken prior to receipt of your written request. Here is what you need to know: This form is used to release your PHI. By signing this form, you allow us to share or use your health information. This information may identify you to others. Your PHI includes all information about your health, treatments, and medicines. PHI can refer to your physical or mental health. By signing this form, you allow Prestige Health Choice to release your PHI to a person or organization you choose. Even if you sign the form, you can still change your mind about sharing information. Just let us know. You can tell us by mailing a letter to our office. Once we receive the letter, we will stop using your information. But we cannot take back any information we shared before you revoke the authorization. Contact Member Services at for more information. Section A. Member information Tell us the individual whose information will be released. Name (first, middle, last): Member ID number: Date of birth (month/day/year): Address (including ZIP code): Phone number (including area code): Section B. Health plan information Tell us the organization that will release your information. I authorize Prestige Health Choice to release my PHI. Page 1 of 4

50 Authorization for Disclosure of Health Information Section C. Recipient information Tell us the person or organization that will receive your information (attach additional pages as necessary). Name of person or organization: Phone number (including area code): Fax number (if available): Address (including ZIP code): Name of person or organization: Phone number (including area code): Fax number (if available): Address (including ZIP code): Section D. Description of the information to be released Tell us what type of information we can share. Check only one box. Psychotherapy notes. These are notes from a mental health professional. Federal law requires a separate authorization to use or release psychotherapy notes. (If you check this box, you may not check another box below. You can fill out another form to release other information.) All information related to the provision of and payment for my health care benefits or services. This excludes any period of time during which a Confidential Communication Address was in effect. Specific information as described in the box below: Examples: The claim related to my service on [date]. Appeal information related to my claim on [date]. Note: Some laws might require that you give specific permission to release the information below even if you checked a box above. Please check the boxes below that relate to information it is OK to share. By checking these boxes and initialing, you give permission for Prestige Health Choice to release that information. Genetic information Initials: Sexually transmitted disease Initials: HIV/AIDS Initials: Abortion and family planning Initials: Substance or alcohol use Initials: Mental or behavioral health Initials: Let us know why you are releasing this information: Page 2 of 4

51 Authorization for Disclosure of Health Information Section E. Expiration Tell us when this authorization will end:* Check only one box. This authorization will expire: When I revoke this authorization.* When my coverage with Prestige Health Choice ends. Upon the following date, event or condition: * * The party identified in Section B must be notified in writing of the event or condition to cancel or revoke this authorization. This consent is subject to revocation at any time except to the extent that the program that is to make the disclosure has already taken action in reliance on it. Section F. Approval You or your personal representative must sign and date this form for it to be complete. I understand that this authorization to release information is voluntary and is not a condition of enrollment in Prestige Health Choice, eligibility for benefits or payment of claims. I also understand that if the person or organization I authorize to receive the information described above is not subject to health information privacy laws, they may further release the PHI and health information privacy laws may no longer protect it. Here is what you need to know: It is your choice to sign this form. Your benefits will not change if you do not sign the form. You will still be a Prestige Health Choice member. But if you do not sign this form, we cannot share your information or give your PHI to the people you want us to give it to. It is important to know that the person or organization that receives your PHI may be able to release it further. By signing below, I authorize the release of my PHI as described above. Member name (print): Member signature: Date: Personal representative information: A personal representative is a person who has the legal authority to act on behalf of an individual. A copy of a power of attorney or other legal documentation must be on file at Prestige Health Choice or submitted with this form. Printed name of personal representative: Description of representative s authority: Signature of personal representative: Date: Phone number (including area code): Return the completed authorization form to: Prestige Health Choice P.O. Box 7181 London, KY You can also fax it to us at Page 3 of 4

52 This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. EWM Page 4 of 4

53 Personal Representative Request Form Please print clearly in blue or black ink. This form will need to be completely filled out for it to be processed. This includes attaching legal documentation. This form allows another person to make health care decisions for a Prestige Health Choice member. This person should have legal authority to act on your behalf. This includes legal guardianship or health care power of attorney. If you have questions, you can call Member Services. Their phone number is located on the back of your ID card. Member information Name (first, middle, last): Member ID number: Address (including ZIP code): Home phone number (including area code): Daytime phone number (including area code): Date of birth (month/day/year): Gender: Male Female Please write down your health plan name as it appears on your member ID card. Your health plan is your insurance carrier (HMO or MCO). Health plan: Personal representative information Name (first, middle, last): Address (including ZIP code): Maiden name of personal representative s mother: (This will be used for security purposes.) Phone number (including area code): A copy of legal documentation must be attached to this form. If you do not attach legal documentation, this form cannot be processed. Type of documentation you are attaching: Power of attorney for health care decisions. Other (please specify): Legal guardianship. Custodial order. Executor of estate. Signature and date of member s legal personal representative Name (print): Personal representative s signature: Date: Please keep a copy of this form for your records. Page 1 of 2

54 Personal Representative Request Form Important information about personal representatives Legal information: The federal Privacy Rule requires Prestige Health Choice to follow certain procedures before it may provide access to your protected health information (PHI) to someone other than you. PHI is information about you that can reasonably be used to identify you and that relates to your past, present, or future physical or mental health or condition and the provision of health care to you or the payments for that care. Prestige Health Choice will release PHI to your personal representative upon receipt of documentation supporting their legal authority to make health-related decisions on your behalf (for example, a valid power of attorney, guardianship, or other legal document). Prestige Health Choice will also recognize as a personal representative an executor, administrator or a person recognized by law as having authority to act on behalf of a deceased member or the member s estate. What you need to know Information about your health is very personal. We are committed to protecting your privacy. Please read this form carefully. This form will need to be completely filled out for it to be processed. This includes attaching legal documentation. By signing this form, you allow your health information to be shared with your personal representative. Legal information: Prestige Health Choice will not treat someone as your personal representative if we reasonably believe: (1) you may be subject to domestic violence, abuse, or neglect by the personal representative; (2) treating the person as your personal representative could endanger you; or (3) in the exercise of professional judgment (for example, in a licensed professional s judgment), Prestige Health Choice decides that it is not in your best interest to treat the person as your personal representative. What you need to know We care about your well-being. If we think your personal representative will misuse your health information, we will not give it to him or her. Legal information: A personal representative designation will remain in effect until the member, a court order, or an applicable law revokes it. What you need to know If you allow for a personal representative, this document will remain effective until it is canceled. You can cancel this if you want to. You just have to tell us. Court order or other laws can also cancel it. Legal information: To assist Prestige Health Choice in responding to this request, please complete this form by printing or typing into the spaces provided. Attach additional pages if necessary to clarify your request. Attach a copy of the document supporting your personal representative s legal authority to act on your behalf. What you need to know This form will need to be completely filled out for it to be processed. This includes attaching legal documentation. You may use additional pieces of paper if you need more space to write. Mail or fax the completed form and supporting documentation to: Prestige Health Choice P.O. Box 7181 London, KY Fax number: Questions? Call Member Services. The number is on the back of your ID card. Please keep a copy of this form for your records. This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. EWM Page 2 of 2

55 Re: Continuity of Care notice Dear Member: Welcome to Prestige Health Choice. We want to help you get the best care and service possible. You may be seeing a doctor that is not part of the Prestige network. We will work to help you continue your current care until you meet with your Prestige primary care provider (PCP). This is called your Continuity of Care time. It is your first 60 days with us. Your Continuity of Care time ends 60 days after your start date. You can see your start date on your member ID card. It is important that you make an appointment with your Prestige PCP and talk about the care you had before you joined Prestige. You and your Prestige PCP may talk about the care you need in the future. Your PCP s information is on your member ID card. Please make an appointment with your assigned PCP in the next 30 days to discuss your care. Please call our Rapid Response and Outreach Team at , if you need help getting an appointment to see your PCP. Sincerely, Prestige Health Choice This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. ML1146_1701

56 How and Where to Get Care Get care now Call first Get care quickly (within 24 hours) Get care soon Is it an emergency? Yes Call 911 for problems like: Chest pain. Choking. Poisoning. Severe wound/heavy bleeding. Breathing problems. Severe spasms/convulsions. Loss of speech. Broken bones. Severe burns. Drug overdose. Sudden loss of feeling or not being able to move. Severe dizzy spells, fainting, or blackouts. Feelings that will not go away of wanting to hurt yourself or someone else. I don t know Before going to the emergency room: Please call your PCP or the 24/7 Nurse Call Line at No Do you need urgent care? Visit an urgent care center for problems like: Coughing. Vomiting. Diarrhea. Sore throat. Colds. Pink eye. Yes No Stomachache. Rashes. Bruises. Animal bites. Toothache call your dentist or Member Services if you don t have a dentist. Call your doctor or the 24/7 Nurse Call Line for problems like: Sunburn. Sexually transmitted disease (STD). Earache. Sprains. Fever. Minor cuts.

57 This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, seven days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. PRES M1010_1604

58 Dear Member: Thank you for choosing Prestige Health Choice as your health plan. We want you to have the best care. To help with your care, we need to make sure we have the right contact information for you. Please complete the form on the back of this letter, or call Prestige at to speak to one of our Member Services representatives if you ve changed your: Name. Mailing address. Home address. County where you live. Phone number (please list all numbers where we can reach you). (optional). You should also update your contact information with the following agencies: Department of Children and Families: Social Security Administration: If you complete the contact form, mail it to: Prestige Health Choice P.O. Box 7181 London, KY Sincerely, Prestige Member Services This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. ML1003_1701

59 Prestige Health Choice Member Contact Form First name Last name Home address City County State ZIP code Mailing address City State ZIP code Phone number Alternate number address ML1003_1401

60 Welcome to Prestige Health Choice. Now that you are a member, we ask that you please fill out this form. It will help us understand your needs and how to best support you with programs and services. If you need help completing this form, please call our Rapid Response and Outreach Team at and a health plan representative will help you. INITIAL HEALTH SCREENING QUESTIONNAIRE CONTACT INFORMATION First name: M.I.: Last name: Address: City: State: ZIP code: Phone (Best number to reach you): Date of birth: LANGUAGE PREFERENCES Which language is most comfortable for you to speak about your health? English. Bosnian. Somali. Russian. Spanish. French. Arabic. German. Vietnamese. Other: Which language is most comfortable for you to read about your health? English. Bosnian. Somali. Russian. Spanish. French. Arabic. German. Vietnamese. Other: ETHNICITY AND RACE What is your ethnicity? Hispanic. Non-Hispanic. If Hispanic or Latino, what is your country of origin? Other: How do you describe your race? American Indian or Alaskan Native. Middle Eastern or North African. Native Hawaiian or Pacific Islander. Decline to state. Black or African American. Asian. White or Caucasian. Other: New Member Health Risk Assessment 1 Prestige Health Choice

61 New Member Health Risk Assessment Fill out these questions to help us better serve you. Health Risk Assessment questions At Prestige Health Choice (Prestige), we know that health is more than what happens at your doctor s office. We would like to ask you some questions about your everyday needs. Based on your answers, someone from Prestige may contact you to discuss resources in your community. This information is private and protected like all of your health information, and all questions are optional. New Member Health Risk Assessment 2 Prestige Health Choice

62 New Member Health Risk Assessment Fill out these questions to help us better serve you. 1. Can you tell me the last grade you finished in school? No high school. Some high school. High school graduate. GED or high school equivalency. Finished vocational or trade program. Some college. College. Graduate or higher. I choose not to answer this question. 2. It can be challenging to understand when people at the doctor s office talk to you about your health. Do you ever get confused answering or asking questions about your health at appointments? Yes. Please check all that apply: Understanding my doctor s instructions. Reading my doctor s instructions. Understanding how to take medications. Understanding medical terms. Understanding lab results and test results. Other: No. I choose not to answer this question. 3. Sometimes it can be challenging to get transportation for your everyday needs. Have you had trouble getting rides for your health needs in the past four weeks? This can be a ride to the doctor or to get your medicine. What about going to the food store or to work? (Select all that apply). Yes, I have had trouble getting to the doctor or getting my medicine. Yes, I have had trouble getting other places I need to go. No. I choose not to answer this question. New Member Health Risk Assessment 3 Prestige Health Choice

63 New Member Health Risk Assessment Fill out these questions to help us better serve you. 4. It can be stressful to have trouble with paying bills and getting everyday things that you need. Over the past year, have you had trouble with any of the following items: a. Getting food for your family regularly? Yes. q No. I choose not to answer this question. b. Paying your utilities bill (such as heating or electrical)? Yes. q No. I choose not to answer this question. c. Getting the clothing you or your family need? Yes. q No. I choose not to answer this question. d. Getting child care when you need to go to a doctor s appointment? Yes. q No. I choose not to answer this question. e. Paying your phone bill? Yes. q No. I choose not to answer this question. f. Getting everyday items you need (such as diapers, shampoo, blankets, and mattresses)? Yes. q No. I choose not to answer this question. g. Trouble with something else? 5. Having shelter is an important part of your health. Can you tell me about your housing today? I have housing. I have housing, but I am worried about losing it. I don t have housing. I choose not to answer this question. 6. Who is completing the survey? Member. Parent or guardian. Other. Name of parent or guardian or other: New Member Health Risk Assessment 4 Prestige Health Choice

64 New Member Health Risk Assessment 7. Are you pregnant? Yes. No. 8. In general, would you say your health is: Excellent. Very good. Good. Fair. Poor. 9. Do you or your child have any illnesses? Asthma. Diabetes. High blood pressure or cholesterol. Seizures or convulsions. Behavioral health. Sickle cell disease. Attention deficit hyperactivity disorder. Other: 10. Are you (or your child) having a problem going to see your doctor or specialist for a visit? Yes. No. I don t have a doctor I see regularly. 11. What transportation do you (or your child) usually use for medical appointments or services? Drive myself. Taxi. Caregiver or friend. Public transportation. Ambulance. No reliable transportation. Other: 12. Do you (or your child) take any medications? q Yes. q No. New Member Health Risk Assessment 5 Prestige Health Choice

65 New Member Health Risk Assessment 13. If yes, do you (or your child) need help getting your medications? q Yes. q No. 14. Do you (or your child) use any tobacco products? No. Cigarettes or cigars. Smokeless tobacco (chewing tobacco, pipes, e-cigarettes, vapes). 15. Are you (or your child) around people who smoke tobacco products? q Yes. q No. 16. Do you (or your child) have any problems with walking, bathing, dressing, or using the toilet? q Yes. q No. 17. Do you (or your child) use any medical equipment? q Yes. q No. List medical equipment: 18. If yes, do you (or your child) need assistance in getting equipment, supplies, or home care items? q Yes. q No. 19. Are you (or your child) currently receiving any behavioral health services? q Yes. q No. 20. Would you (or your child) like to receive help with behavioral health services? q Yes. q No. 21. Do you (or your child) see a dentist? q Yes. q No. Name of dentist: 22. Do you feel that your (or your child s) illness or condition is not under control? q Yes. q No. New Member Health Risk Assessment 6 Prestige Health Choice

66 New Member Health Risk Assessment Thank you for completing our health assessment! This information will help us provide you the best possible care. We will keep your information private. Please return this form in the postage-paid return envelope or send to: Prestige Health Choice P.O. Box 7181 London, KY You may also fax the completed form to If you have any questions concerning this form, please call Member Services at New Member Health Risk Assessment 7 Prestige Health Choice

67 This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. PRES M1012_1708

68 Prestige Health Choice Mobile App Download our mobile app today! The Prestige Health Choice (Prestige) mobile app helps keep you up-to-date on your health care information. Have you ever: Arrived at the doctor s office without your ID card? Had to select a new doctor or specialist? Been lost on your way to an appointment? Had a question about your benefits? Wanted to call Prestige but could not find our phone number? The Prestige mobile app can help! The mobile app is available for iphone and Android smartphones under the app name PHC Mobile. To get the mobile app, visit the Google Play or Apple App Store. The Prestige mobile app is available at no cost!* Apple Android Don t have a smartphone? Manage your care and get health information from our member portal. Visit to access the member portal. Scan the Apple or Android code to download the app. For more information, please call Member Services at (TTY/TDD ). This app is also available in Spanish and Haitian Creole. Esta aplicación es también disponible en español. Aplikasyon sa a disponib an Kreyòl ayisyen. *Standard messaging and data fees may apply. This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, seven days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. PRES_

69 ML1306_1707 Dear Member: Prestige Health Choice has chosen PerformSpecialty to provide specialty pharmacy services for members. Prescriptions for specialty medications will be filled by PerformSpecialty. Specialty medications are drugs that are high cost and treat complex conditions. They require extra support to make sure they are used correctly. If you are getting a specialty medication from another pharmacy in our network, we will send your prescription to PerformSpecialty for future refills if you need them. If you agree with this choice, you do not need to take any other steps. If you want to choose another pharmacy, or if you have questions, please call PerformRxSM customer service at Sincerely, Prestige Pharmacy Department This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestronúmero de Servicio al Cliente al o TTY/TDD , las 24 horasdel día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7.

70 Discrimination is against the law Prestige Health Choice complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Prestige does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Prestige: Provides free aids and services to people with disabilities to communicate effectively with us, such as: -- Qualified sign language interpreters. -- Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: -- Qualified interpreters. -- Information written in other languages. If you need these services, contact Prestige at (TTY ). We are available 24-hours, 7 days a week. If you believe that Prestige has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Fax: You can file a grievance by mail, fax, or phone. If you need help filing a grievance, Prestige Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at: La discriminación está en contra de la ley Prestige Health Choice cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, origen nacional, edad, discapacidad o sexo. Prestige no excluye a las personas ni las trata de modo diferente debido a su raza, color, origen nacional, edad, discapacidad o sexo. Prestige: Proporciona a las personas con discapacidades, para que puedan comunicarse con nosotros eficazmente, asistencia y servicios gratuitos, tales como: -- Intérpretes calificados del lenguaje de señas. -- Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). Proporciona servicios sin cargo a personas cuyo idioma principal no es el inglés, por ejemplo: -- Intérpretes calificados. -- Información escrita en otros idiomas. Si necesita estos servicios, llame a Prestige al (TTY ). Estamos disponibles las 24 horas del día, los 7 días de la semana. Si cree que Prestige no ha provisto estos servicios o ha discriminado de otra manera en función de raza, color, origen nacional, edad, discapacidad o sexo, usted puede presentar una queja formal dirigida a: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Fax: Puede presentar una queja formal por correo postal, fax o teléfono. Si necesita ayuda para presentar una queja formal, Servicios al Miembro de Prestige está disponible para ayudarlo. También puede presentar una queja relativa a los derechos civiles ante el Departamento de Salud y Servicios Humanos de los EE.UU., Oficina de Derechos Civiles (en inglés, U.S. Department of Health and Human Services, Office for Civil Rights) de manera electrónica a través del Portal de Quejas sobre Derechos Civiles, disponible en portal/lobby.jsf, o por correo postal o teléfono a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Los formularios de quejas están disponibles en:

71 Zak diskriminasyon pa ann amoni ak lalwa Prestige Health Choice dakò ak lwa federal sou dwa sivil yo epi li pa fè diskriminasyon sou baz ras, koulè, peyi kote w soti, laj, andikap oswa sèks ou. Prestige pa mete sou kote oswa trete moun lòt jan akoz ras, koulè, peyi kote w soti, laj, andikap oswa sèks ou. Prestige: Bay moun ki gen andikap asistans ak sèvis gratis pou kominike fasilman ak nou, tankou: -- Entèprèt konpetan nan lang siy. -- Enfòmasyon sou lòt fòma (gwo karaktè, odyo, fòma elektwonik aksesib, lòt fòma ankò). Bay moun ki pa fò nan anglè sèvis lang gratis, tankou: -- Entèprèt konpetan. -- Enfòmasyon ki ekri nan lòt lang. Si w ta bezwen youn nan asistans sa yo, kontakte Prestige nan (TTY ). Nou disponib 7 jou sou 7 epi 24 sou 24. Si w ta konstate Prestige neglije bay sèvis sa yo oswa fè diskriminasyon kèlkonk sou baz ras, koulè, peyi kote w soti, laj, andikap oswa sèks, ou ka depoze yon doleyans nan: Grievance and Appeals, PO Box 7368, London, KY (TTY ), Faks: Ou ka depoze yon doleyans pa mwayen imèl, faks, oswa telefòn. Si w gen difilte pou w depoze yon doleyans, yon Manm nan Sèvis Prestige la ap kontan ede w. Ou ka pote yon plent sou dwa sivil bay Depatman Sante ak Sèvis Dwa Moun Etazini an ak Biwo Dwa Sivil la pa mwayen elektwonik, ou ka fè sa sou Paj pou Plent Biwo pou Dwa Sivil la nan lobby.jsf, oswa pa mwayen kourye oswa telefòn nan: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Fòmilè pou plent yo disponib nan: Multi-language interpreter services English: ATTENTION: If you speak English, language assistance services, free of charge [at no cost], are available to you. Call Spanish: ATENCIÓN: Si usted habla español, tiene a su disposición servicios de asistencia lingüística de forma gratuita [sin costo]. Llame al Haitian Creole: ATANSYON: Si w pale Kreyòl ayisyen, ou kapab jwenn sèvis ki gratis [san sa pa koute w anyen] pou ede w nan lang pa w. Rele nan Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان )بدون تكلفة(. اتصل برقم Chinese Mandarin: 注意 : 如果您说中文普通话 / 国语, 我们可为您提供免费语言援助服务 [ 无需付费 ] 请致电: Chinese Cantonese: 注意 : 如果您使用粵語, 您可以免費獲得語言援助服務 [ 無需付費 ] 請致電 Syriac: Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí [không mất tiền] dành cho bạn. Gọi số Albanian: VINI RE: Nëse flisni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë [pa asnjë shpenzim nga ana juaj]. Telefononi në Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를비용부담없이 [ 무료로 ] 이용하실수있습니다 번으로전화해주십시오. Bengali: লক ষ য কর ন আপনন যন ব ল য় কথ বললন ত হলল নবন ম ললষ য [নন খরচ য়] ভ ষ সহ য়ত পনরলষব প লবন এর জনষ য নম বলর ফ ন কর ন Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej [bez żadnych kosztów] pomocy językowej. Zadzwoń pod numer German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen gebührenfrei (kostenlos) sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: French: ATTENTION : si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement [sans coût]. Appelez le Japanese: 注意事項 : 日本語を話される場合 言語支援フリーサービス ( 無料 ) をご利用いただけます まで お電話にてご連絡ください Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные [на безвозмездной основе] услуги перевода. Звоните Serbo-Croatian: PAŽNJA: Ako govorite srpsko-hrvatski, na raspolaganju su vam besplatne usluge tumača [bez naplate]. Nazovite Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari mong mapakinabangan ang libreng [walang bayad] language assistance service (pag gabay sa wikang Tagalog). Tumawag sa PRES

72 Notice of Privacy Practices Effective May 1, 2012 (Revised February 7, 2017)