300 Hillmont Avenue, Ventura, CA 93003 (805) 652-6165 or (805) 652-6000
Santa Paula Hospital
A Campus of Ventura County Medical Center
825 N Tenth Street Santa Paula, CA 93060 (805) 933-8632 or (805) 933-8600
Ventura County Health Care Plan on call Administrator available 24 hours per day for Emergency Providers (805) 981-5050 or (800) 600-8247
THE NURSE ADVICE LINE 1-800-334-9023
Available 24 hours a day, 7 days a week for Member questions regarding their medical status, about the health plan processes, or just general medical information.
THERE IS ALSO A LINK ON THE MEMBER WEBSITE: vchealthcareplan.org/members/memberIndex.aspx that will take Members to a secured email where they may send an email directly to the advice line. The nurse advice line will respond within 24 hours.
To speak with VCHCP UM Staff, please call The Ventura County Health Care Plan at the numbers below:
QUESTIONS? CONTACT US:
MONDAY - FRIDAY, 8:30 a.m. to 4:30 p.m.
Phone: (805) 981-5060 or toll-free (800) 600-8247
FAX: (805) 981-5051, vchealthcareplan.org
TDD to Voice: (800) 735-2929 Voice to TDD: (800) 735-2922
Ventura County Health Care Plan 24-hour Administrator access for emergency providers: (805) 981-5050 or (800) 600-8247
Language Assistance - Language Line Services: Phone (805) 981-5050 or toll-free (800) 600-8247
2•1•1 can assist patients with counseling, food assistance, domestic violence services, employment resources,
TIMELY ACCESS REQUIREM EN TS
VCHCP adheres to patient care access and availability standards as required by the Department of Managed Health Care (DMHC). The DMHC implemented these standards to ensure that members can get an appointment for care on a timely basis, can reach a provider over the phone and can access interpreter services, if needed. Contracted providers are expected to comply with these appointments, telephone access, practitioner availability and linguistic service standards. If a timely appointment is not available at any of our contracted clinics/facilities, then an out-of-network (OON) referral request should be sent by the referring provider to the Plan for authorization. The authorization request must include the details regarding the access issue and why an OON referral is required.
Note: The referring provider may allow for an appointment outside of the timely access requirements if it will not be harmful to the patient’s health. These instances must be documented in the patient’s chart and communicated to the patient.
VCHCP Member Portal
As a VCHCP Member, you can access your personal Health Plan information online by creating a profile through the VCHCP Member Login link found on the Plan’s website: vchealthcareplan.org
Once you are logged in you will be able to access personalized information about your:
• Benefits
• Claims Status
• Authorizations Status
You will also be able to:
• Request ID Cards
• Print your ID Cards
• Submit Reimbursement Forms
• Submit a General Plan or Coverage Question
To register for the portal…
- Go to vchealthcareplan.org
- Click on “For Members”
- Click on “VCHCP Member Portal
For questions on accessing the portal, please contact Member Services at (805) 981-5050 or (800) 600-8247, Monday – Friday 8:30 a.m. – 4:30 p.m., or email VCHCP.Memberservices@ventura.org
Language and Communication Assistance
Good communication with VCHCP and with your providers is important. If English is not your first language, VCHCP provides interpretation services and translations of certain written materials.
• To ask for language services call VCHCP at (805) 981-5050 or (800) 600-8247. You may obtain language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner. You may obtain interpretation services free of charge in English and the top 15 languages spoken by limited-English proficient individuals in California as determined by the State of California Department of Health Services.
• If you are deaf, hard of hearing or have a speech impairment, you may also receive language assistance services by calling TDD/TTY at (800) 735-2929 .
• If you have a preferred language, please notify us of your personal language needs by calling VCHCP at (805) 981-5050 or (800) 600-8247
• Interpreter services will be provided to you, if requested and arranged in advance, at all medical appointments.
If you have a disability and need free auxiliary aids and services, including qualified interpreters for disabilities and information in alternate formats, including written information in other formats, you may request that they be provided to you free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity for you to participate.
How Often Should You See Your
Primary Physician?Care
How to Find a Provider
The online Provider Directory is updated weekly thus providing the most accurate information available. This can be found in our website vchealthcareplan.org via the “Find a Provider” link. For a printed copy of the directory contact Member Services at (805) 981-5050 or (800) 600-8247 or email VCHCP.Memberservices@ventura.org
Select your plan:
Select a provider type:
Select a specialty:
Select a city:
Select a language:
Select a gender:
Select Name of Clinic...
Select Name of Hospital...
TIP: When searching for a specialist, make sure to select a specialty but ensure that the provider type is set at “All Provider Types” as selecting a provider type will limit the options available.
Your Primary Care Provider (PCP) is responsible for treating you when you are sick or injured, and at times is the coordinator of referrals to specialists and other services. Some members rarely see their PCP, which can make care difficult, especially in an emergent situation. Children and Adults should be seen by their PCP at least yearly (more frequently for children under 2 years of age). Preventive Health Visits, or Check-ups should occur regularly to have appropriate preventive screenings, immunizations, and an overall review of your health. This is an important visit to discuss health concerns or even health goals. Staying in contact with your PCP by having annual check-ups can help with establishing a good relationship with your PCP. This relationship can make times of illness or injury run smoother and give you peace of mind for the care you receive.
If you haven’t had a checkup in the last year, please call your PCP today to make an appointment. If you need assistance or have questions, please call Member Services at (805) 981-5050.
ACCESSING Behavioral Healthcare SERVICES
Contact OptumHealth Behavioral Solutions of California “Life Strategies” Program at (800) 851-7407 or visit the website at liveandworkwell.com/content/en/public.html.
Contact VCHCP Member Services at (805) 981-5050 to request an EOC copy or go to the Plan’s website at vchealthcareplan.org/members/programs/docs/ countyemployees/EOCCountyAndClinicEmp2023.pdf.
Optum contact information can also be found at the back of your VCHCP health insurance card.
Information on authorization of Plan Mental Health and Substance abuse benefits is available by calling the Plan’s Behavioral Health Administrator (BHA) at (800) 851-7407. A Care Advocate is available twenty-four (24) hours a day, seven (7) days a week to assist you in accessing your behavioral healthcare needs. For non-emergency requests, either you or your Primary Care Provider may contact Life Strategies for the required authorization of benefits prior to seeking mental health and substance abuse care.
Further information may also be obtained by consulting your Ventura County Health Care Plan Commercial Members Combined Evidence of Coverage (EOC) Booklet and Disclosure Form.
Direct Specialty REFERRALS
A “Direct Specialty Referral” is a referral that your Primary Care Physician (PCP) can give to you so that you can be seen by a specialist physician or receive certain specialized services. Direct Specialty Referrals do not need to be pre-authorized by the Plan. All VCHCP contracted specialists can be directly referred by the PCPs using the direct referral form [EXCLUDING TERTIARY REFERRALS, (e.g. UCLA AND CHLA)]. Referrals to Physical Therapy and Occupational Therapy also use this form.
Note that this direct specialty referral does not apply to any tertiary care or non-contracted provider referrals. All tertiary care referrals and referrals to non-contracted providers continue to require approval by the Health Plan through the treatment authorization request (TAR) procedure.
Appointments to specialists when you receive a direct referral from your PCP should be made either by you or by your referring doctor. Make sure to check with your referring doctor about who is responsible for making the appointment.
Appointments are required to be offered within a specific time frame, unless your doctor has indicated on the referral form that a longer wait time would not have a detrimental impact on your health. Those timeframes are: Non-urgent within 15 business days, Urgent within 48-96 hours.
If you or your doctor feel that you are not able to get an appointment within an acceptable timeframe, please contact the Plan’s Member Services Department at (805) 981-5050 or (800) 600-8247 so that we can make the appropriate arrangements for timeliness of care.
The Direct Referral Policy can also be accessed at: vchealthcareplan.org/providers/docs/medpolicies/DirectSpecialtyReferral.pdf
To request to have a printed copy of the policy mailed to you, please call Member Services at the numbers listed above.
Standing REFERRALS
A standing referral allows members to see a specialist or obtain ancillary services, such as lab, without needing new referrals from their primary care physician for each visit. Members may request a standing referral for a chronic condition requiring stabilized care. The member’s primary care physician will decide when the request meets the following guidelines. A standing referral may be authorized for the following conditions when it is anticipated that the care will be ongoing:
• Chronic health condition (such as diabetes, COPD etc.)
• Life-threatening mental or physical condition
• Pregnancy beyond the first trimester
• Degenerative disease or disability
• Radiation treatment
• Chemotherapy
• Allergy injections
• Defibrillator checks
• Pacemaker checks
• Dialysis/end-stage renal disease
• Other serious conditions that require treatment by a specialist
A standing referral is limited to 6 months, but can be reviewed for medical necessity as needed, to cover the duration of the condition.
If you change primary care physicians or clinics, you will need to discuss your standing referral with your new physician. Changing your primary care physician or clinic may require a change to the specialist to whom your primary care physician makes referrals.
Additional information regarding Standing Referrals is located on our website: vchealthcareplan.org/providers/docs/medpolicies/ StandingReferralsToSpecialists.pdf or by calling Member Services at (805) 981-5050 or (800) 600-8247.
VENTURA COUNTY HEALTH CARE PLAN
OptumHealth QUALITY PROGRAM
contracts with OptumHealth Behavioral Solutions (Life Strategies) for Mental/Behavioral health and substance abuse services. OptumHealth has a Quality Improvement Program (QI) that is reviewed annually.
If you would like to obtain a summary of the progress OptumHealth has made in meeting program goals, please visit OptumHealth’s online newsletter at vchealthcareplan.org/members/docs/OptumHealthNEWSLETTER.pdf or call OptumHealth directly at (800) 851-7407 and ask for a paper copy of the QM program description.
Referral & Prior Authorization Process and Services Requiring Prior Authorization
Need information on how and when to obtain referrals and authorization for specific services? Please visit our website at vchealthcareplan.org/members/priorAuthorizations.aspx and click on “VCHCP’s Referrals and Prior Authorization Process” or click this link to direct you to the page vchealthcareplan.org/providers/docs/PriorAuthorizationProcess.pdf.
This area provides links for members to obtain specific information on the Plan’s prior authorization process, what services require prior authorization, timelines, and direct referral information.
IF YOU HAVE ANY QUESTIONS, PLEASE CALL MEMBER SERVICES AT (805) 981-5050.
A MESSAGE FROM OUR Case Management Nurse
Case Management (CM) is part of your VCHCP benefit, free of charge to all members.
I am dedicated to assist in organizing your healthcare need(s) and assist with coordinating care you may need. I can communicate between your providers to help connect your care and achieve your health goals. I am your advocate and I will help to empower you to manage your health care needs. If you are “lost” in the system of navigating your health care needs, contact CM to discuss your options. If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Manager or Disease Manager. Your call will be returned within 2 business days.
Members can also self-refer to the program online on the Member page at vchealthcareplan.org/members/ requestAssistanceForm.aspx or by scanning this QR Code.
Coordinating Your Care
Your primary care physician is your main contact for maintaining good health and receiving medical care, so selecting a doctor and establishing a strong relationship with them is essential for your well-being.
Your doctor monitors your health and ensures you see the appropriate specialists when necessary. One of your primary care doctor’s responsibilities is coordinating all of your medical care.
If you are receiving services from more than one practitioner or getting care from a specialist, it is
important for all your doctors to communicate valuable information with each other so they can work together to help ensure your care is complete and effective.
How can you help?
Please talk to your practitioner about sharing essential medical information with your PCP by requesting to sign a release of information.
Share with your PCP the names and contact information of your other treating medical practitioners, so your PCP can request medical records.
Diabetic Retinal Exam
What is a diabetic retinal exam?
A diabetic retinal exam lets your eye doctor see the back of your eye (retina). It helps find eye problems such as diabetic retinopathy. This problem occurs when high blood sugar from diabetes damages the small blood vessels in the retina.
Diabetes eye exams
Diabetes can harm your eyes. It can damage the small blood vessels in your retina , the back wall of your eyeball. This condition is called diabetic retinopathy.
Diabetes also increases your risk of glaucoma and other eye problems.
You may not notice that your eyes are damaged until the problem is very bad. Your eye doctor can catch problems early if you get regular eye exams. This is very important. The early stages of diabetic retinopathy don’t cause changes in vision and you won’t have symptoms. Only an eye exam can detect the problem, so that steps can be taken to prevent the eye damage from getting worse.
You Need Regular Eye Exams
Even if the health care provider who takes care of your diabetes checks your eyes, you need an eye exam every 1 to 2 years by an eye doctor who takes care of people with diabetes. An eye doctor has equipment that can check the back of your eye much better than your regular provider can.
disease caused by diabetes, you will likely also see an ophthalmologist.
What happens after the exam?
Dilating drops may make your eyes sting. This will last for a few moments. They may also cause a medicine taste in your mouth. Your eyes will have trouble focusing for up to 6 hours after the test. This will likely affect your near vision more than your far vision.
Your eyes may be sensitive to light. Wearing sunglasses may help until the drops wear off.
Do not drive for a few hours after the test, unless your doctor says it is okay.
If you have eye problems because of diabetes, you will probably see your eye doctor more often. You may need special treatment to prevent your eye problems from getting worse.
You may see two different types of eye doctors:
• An ophthalmologist is a medical doctor who is an eye specialist.
• An optometrist is a Doctor of Optometry. If you develop eye
If your eye exam results are normal, your doctor may do follow-up exams every 2 years instead of every year. But if you have diabetic retinopathy, you may need eye exams more often.
Please share your eye exam results with your PCP and endocrinologist.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments and call your doctor if you are having problems. Ask your doctor when you can expect to have your test results.
When a Treatment Authorization Request (TAR) has been “pended for additional information” it means that VCHCP needs more information from the Provider to complete the TAR review process. THE PROCESS IS AS FOLLOWS:
• When VCHCP clinical staff identifies that additional information is needed to complete a TAR determination, a pend letter will be sent to the requesting provider and to the member for whom the authorization is being requested. The pend letter will indicate that a) the TAR has been pended, b) what information is missing, and c) will provide for up to 45 calendar days (for routine TAR requests) for the requested additional information to be submitted to VCHCP. Per NCQA standards, a TAR can only be pended once, additional requests for information will not be sent and VCHCP will not send a reminder.
• When the information is submitted within 45 days, a final determination will be made within 5 business days for a routine TAR, and notification will be sent to the requesting provider and to the member within 24 hours of the decision*.
• If the requested information is not submitted within 45 days, a final determination will be made based on the initial information submitted and may be denied by the VCHCP Medical Director.
• To assist VCHCP staff with the efficient review of these requests, and to avoid delays in the review process, the following is appreciated at the time the TAR is initially submitted:
“PENDED FOR ADDITIONAL INFORMATION”
◊ Please provide specific clinical information to support the TAR. For example, the History and Physical (H&P), key lab or test results, and plan of care from the most recent office visit (this is usually sufficient) if the office visit specifically relates to the TAR.
◊ For providers using CERNER, please provide the exact place in CERNER where the specific clinical information can be located to support the TAR. “See Notes in CERNER” does not adequately describe what clinical information supports the TAR, and should be reviewed.
◊ If written notes are submitted, please be sure they are legible.
• In addition to faxing pend letters for needed additional information to providers, the Plan’s UM began sending messages through Cerner to inform VCMC requesting provider of pended request and clinical information needed by the Plan to make a medical necessity decision. For Non-VCMC providers, a phone call is placed to the requesting provider of the pended request and clinical information needed by the Plan.
• The Plan’s pend letter was updated with an “Alert” to providers that clinical information is needed.
* These timeframes will apply in most situations. There may be some variance with urgent and retrospective TAR requests. Please see the VCHCP TAR Form for the timeline descriptions. Link: vchealthcareplan.org/providers/docs/preAuthorizationTreatmentAuthorizationForm.pdf
CASE MANAGEMENT &
VCHCP has a Case Management
Program to help our members who have complex needs by ensuring that our members work closely with their doctors to plan their care. Case Management is a collaborative process of assessment, planning, facilitation, and advocacy. Determination is made for the best options and services to meet a member’s individual health needs through communication and utilization of available resources to promote quality care and cost-effective clinical outcomes. The goals of Case Management are to help members get to their best health possible in the right setting; coordinate and manage healthcare resources; support the treatment plan ordered by the doctor; and to take action to improve member overall quality of life and health outcomes. As a member in Case Management, members with complicated health care issues and their family have a truly coordinated plan of care.
Your Healthcare plan for the future starts here!
VCHCP identifies members for Case Management through several referral sources, including health care provider referrals and member self-referrals. Members appropriate for case management referral include those members with medical and psychosocial needs impacting their compliance with disease management and health improvement including increasing severity of condition, safety issues, decreasing functional status, new behavioral health issues, need for caregiver resources. Some examples of eligible medical conditions or events include multiple hospital admissions or re-admissions, multiple chronic conditions, major organ transplant candidates, and major trauma. A member identified for Complex Case Management is considered a participant in the program unless the member decides to opt-out (not accept the services/coordination of care offered). Once a nurse Case Manager evaluates a member, the Case Manager creates a care plan with the member and healthcare team input. The care plan is shared with the member’s doctor for his/her input and review. The care plan is monitored by the Case Manager and coordinated with the member and doctor.
DISEASE MANAGEMENT SERVICES
The VCHCP Disease Management Program coordinates health care interventions and communication for members with conditions where VCHCP support of member self-care activities can improve their conditions. VCHCP has two Disease Management programs: Asthma and Diabetes. VCHCP has systematic processes in place to proactively identify members who may be appropriate for these disease management services. Diagnosis information on claims encounter data and pharmacy data prescription drug information are used to systematically identify members for disease management. Members and providers may also refer to the applicable Disease Management program. Once identified, the member is automatically enrolled in the program unless the member chooses to opt out. The Disease Management team works with doctors and licensed professionals to improve these chronic conditions, so members obtain the best possible quality of life and functioning. Included in the Disease Management Program are mailed educational materials, provider education on evidence-based clinical guidelines, member education over the phone (health coaching) and care coordination. VCHCP has a variety of member materials about diabetes and asthma available to help you better understand your condition and manage your chronic disease. Our goal is to improve the health of our members.
The VCHCP programs for Case Management and Disease Management are for members with severe illnesses and chronic diseases to help plan their care with their primary doctor and learn more about self-care. These programs have nurses who work with members over the phone to guide them towards the best possible health for their conditions.
Participation in these programs is free and voluntary for eligible members. Members can opt out at any time and being in these programs does not affect benefits or eligibility.
For more information or to submit a referral for the Case Management and Disease Management Program, please call 805-981-5060. Members can also self-refer to a program online on the Member page by clicking this link Request Case Management or Disease Management (vchealthcareplan.org).
Complex Case Management, Case Management or Disease Management
In addition to VCHCP medical management staff, hospital discharge planners and practitioners; members and caregivers now have an opportunity to seek assistance for complex and or chronic medical needs such as asthma, diabetes, and coordination of challenging care online!
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, facilitation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
VCHCP’s CCM program is an opt-out program, and all eligible members have the right to participate or decline participation. Verbal consent is obtained prior to formally enrolling the member into the Complex Case Management Program. Members who are identified with the following situations include but are not limited to Transplants, ESRD, Traumatic Brain Injuries and High-Risk Diabetics.
Members can also self-refer to a program online on the Member page at vchealthcareplan.org/members/ requestAssistanceForm.aspx. You will be prompted to enter member specific information.
Members and caregivers can contact Member Services at (805) 981-5050 and request a referral for case management or disease management services. Members can also self-refer to a program online on the Member page at vchealthcareplan.org/members/requestAssistanceForm.aspx. You will be prompted to enter member specific information. You will then submit this form to a secure email. A nurse will evaluate your request and call you within 2 business days.
If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
DISEASE MANAGEMENT & CASE MANAGEMENT REQUEST
HAVE YOUR SAY ABOUT YOUR EXPERIENCE WITH
All VCHCP members who are in our Disease Management or Case Management Programs will receive a survey to evaluate the program they are enrolled in. These surveys are to measure how useful our programs are to the members, and to evaluate where we need to improve. Programs being surveyed include, Diabetes Disease Management, Asthma Disease Management, and Autism Case Management. When you receive the survey, simply complete the questions and return it in the pre-paid envelope. Your responses are completely anonymous.
Thank you in advance for helping us evaluate our programs, making them even better! If you have questions regarding surveys or any of our Disease Management or Case Management programs, call Utilization Management at (805) 981-5060.
HowTo
SUBMITTING AN EXTERNAL EXCEPTION REVIEW REQUEST
for the denial of Request for Step Therapy Exception, Formulary Exception, and Prior Authorization for a Medication
You, your designee, or your prescribing doctor can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization by following the steps below:
• Submit an exception via online request available in the VCHCP member website by clicking Request for Pharmacy/Formulary Exception = Pharmacy Prior Authorization (vchealthcareplan.org) or by calling the Plan at (805) 981-5050
• Ask the Plan to make an exception to its coverage rules.
• There are several types of exceptions that can be requested such as:
- Cover a drug even if it is not on the Plan’s formulary.
- Waive coverage restrictions or limits on a drug. For example, the Plan limit the amount on certain drugs it covers. If the drug has a quantity limit, ask the Plan to waive the limit and cover more.
- Provide a higher level of coverage for a drug. For example, if the drug is in the Non-Preferred Drug tier, ask the Plan to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Drug tier 3 instead. This applies so long as there is a formulary drug that treats your condition on the Preferred Brand Drug tier 3. This would lower the amount paid for medications.
• Once the Plan receives the exception request via website or via phone call, the Plan’s Utilization Management will contact your doctor to process your External Exception Review Request.
• The Plan sends your external exception review request to an independent review organization called IMEDECS/Kepro.
• VCHCP will ensure a decision and notification within 72 hours in routine/standard circumstances or 24 hours in exigent circumstances.
• The Plan will make its determination on the external exception request review and notify the enrollee or the enrollee’s designee and the prescribing provider of its coverage determination no later than 24 hours following receipt of the request, if the original request was an expedited formulary/prior authorization/step therapy exception request or 72 hours following receipt of the request, if the original request was a standard request for nonformulary prescription drugs/step therapy/prior authorization.
• If additional information is required to make a decision, the Plan in collaboration with IMEDECS/Kepro will send a letter via fax to your prescribing doctor advising that additional information is required.
• Exception request for step therapy/nonformulary/ prior authorization will be reviewed against the criteria in Section 1367.206(b) and, if the request is denied, the Plan will explain why the exception request for step therapy/nonformulary/ prior authorization drug did not meet any of the enumerated criteria in section 1367.206(b).
• The exception request review process does not affect or limit the enrollee’s eligibility for independent medical review or to file an internal appeal with VCHCP.
• The enrollee or enrollee’s designee or guardian may appeal a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request by filing a grievance under Section 1368.
• If the independent review organization reverses the denial of a prior authorization, formulary exception, or step therapy request, the decision is binding on the Plan.
• The decision of independent review organization to reverse a denial of a prior authorization, formulary exception, or step therapy request applies to the duration of the prescription including refills.
HOW TO REQUEST A STEP THERAPY EXCEPTION, FORMULARY EXCEPTION AND PRIOR AUTHORIZATION EXCEPTION
Submitting Exception Requests To The Preferred Drug List
Members can request individual exceptions to the preferred drug list through their primary care practitioner or directly to VCHCP by phone or through the VCHCP website.
To submit an exception request to VCHCP, complete the online request form available in the VCHCP member website Request for Pharmacy/Formulary Exception = Pharmacy Prior Authorization (vchealthcareplan.org) or by calling the Plan at (805) 981-5050.
VCHCP will review your exception request and will either contact you or reach out to your doctor to get more clinical information.
A Prior Authorization (PA) request can be submitted by the practitioner on the member’s behalf to VCHCP for consideration. Practitioners may themselves also initiate a petition for consideration of coverage. Practitioners should include relevant clinical history, previous medications prescribed and tried, contraindications or allergies to medications and any other contributory information deemed useful. VCHCP will review the information according to the PA policy. Because the PA requests are reviewed by the Plan and not the PBM, if the medication does not meet criteria on initial review by the nurse reviewer, it is reviewed by a physician reviewer and special consideration is given to the exception request based on the information received. The physician reviewers are also available by phone to discuss an exception request with the practitioner.
Population Health Management Programs
Ventura County Health Care Plan provides ongoing support of our members to meet their healthcare needs. Our goal is to empower you to take control of your health. VCHCP wants to be sure you are aware of the many programs, services, and activities offered by us to support you in your health care goals. Please visit our website at VCHCPPopulationHealthManagement.pdf (vchealthcareplan.org)
to see the list of programs/services offered, how you are eligible to participate, and how you decide to participate. If you need further information or have any questions regarding the programs or activities offered, please contact our Health Services Department at (805) 981-5060 or toll-free (800) 600-8247. Guidelines, please contact Member Services at (805) 981-5050 or at (800) 600-8247.
EDUCATION MATERIALS
FAQ’s FAQ’s
FOR MEMBERS ABOUT SPECIALTY MEDICATIONS
➠ It is very important that you remain proactive in following up with your specialty medication. This will minimize the delay in getting timely medications.
What is a “Specialty Medication”?
Specialty Medications are high-cost medications, regardless of how they are administered (injectable, oral, transdermal, or inhalant), and are often used to treat complex clinical conditions that require close management by a physician due to their potential side effects and the need for frequent dosage adjustments.
What if my Doctor prescribes a “Specialty Medication” for me?
Most “Specialty Medications” require prior authorization from the Plan. Your doctor will need to complete a Prescription Drug Prior Authorization Request form and submit it to the Health Plan for approval.
How do I know if my medication is a “Specialty Medication”?
Contact Accredo at (800) 803-2523. Accredo is Express Scripts’ specialty pharmacy provider.
How much will my specialty medication cost?
You can look up your out-of-pocket cost for any medication (whether specialty or not) by going to the Express Scripts website at express-scripts.com and creating an online account. Or you can call Express Scripts directly at (800) 811-0293 to find out your out-of-pocket cost for a particular medication or for help logging into their website.
How do I get my specialty medication?
Once the Health Plan approves your doctor’s Treatment Authorization Request, Accredo verifies the approval and contacts the patient to coordinate shipment of the medication to the patient’s address within 24 to 48 hours. Accredo cannot ship your medication without speaking with you directly to arrange shipment.
If you receive a message from Accredo, you will need to call Accredo back. Accredo will also provide any equipment necessary for you to take your medication. You can call Accredo directly with any questions at (800) 803-2523
What
if I need
to start taking my medicine right away?
If your doctor determines that it is medically necessary for you to begin taking the medication right away, he/she can write a prescription for a 1 time 30-day supply to be filled at a local pharmacy upon approval by the Plan.
What if my medication hasn’t arrived yet?
If you are concerned about the amount of time it is taking for your medication to be shipped to you, or if you have any other questions or concerns, please call the Plan’s Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 Monday through Friday between the hours of 8:30 am and 4:30 pm.
For more information about the Plan’s Specialty Medication policies or Prescription Medication Benefit Program please see the Plan’s website at vchealthcareplan.org/providers/priorAuthDrugGuidelines.aspx or call the Plan’s Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 between the hours of 8:30 am and 4:30 pm Monday-Friday.
EMERGENCY ROOM VISIT
Copays and Follow Up
No one likes Emergency Room (ER) visits, nor how pricey they can become.
Avoid having to pay multiple ER copays by ensuring that you see your Primary Care Provider (PCP) for any follow-up care. Just a reminder... Additional ER copays will be applied when returning for follow-up care at the ER.
A sudden trip to the ER can be difficult and often times results in a change in medication or treatment. After a visit to the ER, it is very important that you make an appointment to see your PCP and specialist when applicable, as soon as possible, or within 30 days. This visit is to update your PCP on what occurred that required you to seek emergency treatment, update
Care for Individuals Diagnosed with Schizophrenia and/or Prescribed Antipsychotic Medication
your medication routine, and to be referred for additional care if needed. Establishing and keeping a good relationship with your PCP is vital to your health and your PCP’s ability to provide care to you.
If you find that making an appointment with your PCP or specialist after an ER visit is difficult and you can’t be seen within 30 days, or if your ER visit was due to your inability to be seen by your PCP, please notify your Ventura County Health Care Plan Member Services Department at (805) 981-5050. Your ability to access health care is important to us.
Regular care is crucial for individuals with schizophrenia or those prescribed antipsychotic medications. Here’s wahat you can do:
✓ Health Monitoring: Get metabolic/lipid tests annually, including HbA1c or blood glucose and LDL-C or cholesterol levels.
✓ Medication Adherence: Stay on track with your prescribed medications. Educate yourself, be patient, and communicate openly with your healthcare provider.
✓ Seeking Support: Utilize resources like liveandworkwell.com for patient education and mental health provider information.
✓ Coordinate Care: Share contact information with your treating providers to ensure comprehensive care. We’re here to support your mental health journey.
References:
- Optum, Inc. All Rights Reserved. BH4885 06/2023
- Recommendations based on the National Committee for Quality Assurance HEDIS® specifications
VCHCP Member Behavioral Health and Substance Abuse RESOURCES
Member Website and Provider Directory: LiveandWorkWell.com
Optum Intake and Care Management For Intake and Referrals: (800) 851-7407
Optum covers all Substance-Use-Disorder services identified in the American Society of Addictions Medicine (ASAM) criteria, and as of January 1, 2021, this includes ASAM levels 3.1 and 3.2 WM services.
Substance Use Disorder
Helpline: 1-855-780-5955
A 24/7 helpline for VCHCP Providers and Patients
If you have paid for these services out of pocket, you can submit claims for retrospective review to the following address:
ANTI-DEPRESSANT Medication Management
Members who are diagnosed with depression and prescribed medication should work closely with their physician to ensure proper treatment. To achieve maximum results from anti-depressant medication, it is important to remain on the medication consistently for at least 6 months, or for the duration prescribed by your physician. VCHCP contracts with Express Scripts for prescription medications. If you have any questions about the services you may need, please contact your physician.
In addition, for Behavioral Health services that you may need, please contact OptumHealth Behavioral Solutions of California “Life Strategies” Program at (800) 851-7407 or visit the website at liveandworkwell.com/content/en/public.html.
If you are seeing a primary care physician (PCP), be sure that your PCP is collaborating care with any of your other providers, especially your mental health specialist. Communication is the key for your overall health care.
For more information, please visit the VCHCP website at vchealthcareplan.org/members/docs/healthEducationInfo/ ClinicianBrochure.pdf.
Optum Claims Processing
P.O. Box 30755
Salt Lake City, UT 84130-0755
Depression is a chronic disease that requires long-term management, typically with medication.
DEPRESSION EDUCATION MATERIALS AVAILABLE
Depression is a common mental illness that can be very limiting. When members are well informed and seek treatment, they can successfully work through life problems, identify coping skills, and retain a sense of control. VCHCP has created a brochure of depression information and resources available to members. This valuable resource is available on the VCHCP website at vchealthcareplan.org/members/docs/healthEducationInfo/ClinicianBrochure.pdf If you do not have access to the website or would like further information, please call (805) 981-5060 and ask to speak with a Disease Management Nurse.
V ENTURA COUNTY HEALTH CARE PLAN CONTRACTS WITH
OptumHealth Behavioral Solutions (LIFE
STRATEGIES)
FOR MENTAL/BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Optum’s Live and Work Well website is packed with valuable information for healthy living. For easy access to this information, look for Optum’s icon on the VCHCP website – click on it and you are on your way to learning more about healthy living! You can also access it through Behavioral Health, EAP, WorkLife & Mental Health Services | Live and Work Well.
Following are two examples of articles available for members to help with common behavioral health issues.
Attention Deficit Hyperactivity Disorder (ADHD)
What is attention deficit hyperactivity disorder?
Attention deficit hyperactivity disorder (ADHD) is a condition in which a person has trouble paying attention and focusing on tasks, tends to act without thinking, and has trouble sitting still. It may begin in early childhood and can continue into adulthood. Without treatment, ADHD can cause problems at home, at school, at work, and with relationships. In the past, ADHD was called attention deficit disorder (ADD).
What causes ADHD?
The exact cause is not clear, but ADHD tends to run in families.
What are the symptoms?
The three types of ADHD symptoms include:
• Trouble paying attention. People with ADHD are easily distracted. They have a hard time focusing on any one task.
• Trouble sitting still for even a short time. This is called hyperactivity. Children with ADHD may squirm, fidget, or run around at the wrong times. Teens and adults often feel restless and fidgety. They aren’t able to enjoy reading or other quiet activities.
• Acting before thinking. People with ADHD may talk too loud, laugh too loud, or become angrier than the situation calls for. Children may not be able to wait for their turn or to share. This makes it hard for them to play with other children. Teens and adults may make quick decisions that have a long-term impact on their lives. They may spend too much money or change jobs often.
How does ADHD affect adults?
Many adults don’t realize that they have ADHD until their children are diagnosed. Then they begin to notice their own symptoms. Adults with ADHD may find it hard to focus, organize, and finish tasks. They often forget things. But they also often are very creative and curious. They love to ask questions and keep learning. Some adults with ADHD learn to manage their lives and find careers that let them use those strengths.
The Basics: Autism Facts
What is Autism?
Autism is a developmental disorder. The disorder makes it hard to understand the world. Communication is especially challenging. It is hard for people with autism to attach meaning to words and facial expressions. Individuals with the disorder have trouble interacting with others. They may seem as if they are in their own world. People with autism tend to engage in repetitive or obsessive behavior. They often do self-harming things. They may bang their heads on the wall or do things like repeatedly pinch themselves.
What are the Symptoms?
Autism is usually noticed in the first three years. Sometimes the symptoms are apparent when comparing the development of your child to others their age. Other times the symptoms may come on all at once. Some signs to look for are:
Communication symptoms:
• Talks late or not at all; speaks loudly or with flat tones
• Points or uses other motions to indicate needs
• Repeats words or phrases without understanding the meaning
• May talk at length about something even if no one is listening
Social interaction symptoms:
• Likes to be alone
• Dislikes being held or touched
• Does not know how to interact; poor listener
• May stare at something for a long time, ignoring the rest of the world
• Poor eye contact
• Does not understand the feelings of others
Behavior symptoms:
• Likes routine; is upset by change
• Does not pretend or use his or her imagination
• May have tantrums or show aggression
• May become very attached
• May engage in repetitive movements like rocking
• May bang his or her head or hurt self
• May be sensitive to noises that others tolerate
• May have an unusual reaction to the way things smell, taste, look, feel or sound
Not everyone experiences autism in the same way. Some may have severe trouble with some things and not be as challenged by others. If you suspect that your child may have autism, trust your instincts. Take your child to a doctor and have them examined.
Additionally, VCHCP has a Case Management Program specific to the needs of those with Autism. Contact the VCHCP Case Management Department for more information (805) 981-5060 or visit vchealthcareplan.org and click on “Request Case Management or Disease Management”.
Autism Screening FOR
ALL CHILDREN
Autism Spectrum Disorder (ASD) is the name for a group of developmental disorders. Studies show that when children with ASD are diagnosed early and receive early intervention, they have improved long-term outcomes. With this in mind, VCHCP has in place a Screening for Autism Policy that all Family Practitioners and Pediatricians caring for children age 2 and younger are to follow. Your child’s provider will administer a standardized screening and surveillance of risk factors at age 18 and 24 months. Also, your provider will perform a general observation at every well-child visit. Please understand that these screenings are to be provided for all children at age 18 and 24 months. If you have concerns about the screening or the results, contact your child’s provider.
If you have any questions about the Autism Screening Policy, please contact VCHCP Utilization Management department at (805) 981-5060.
Autism Spectrum
DISORDERS
Members now have an opportunity to seek assistance for Autism Spectrum Disorders (ASD). VCHCP recommends all members with ASD or parents of children with ASD participate in our Autism Case Management Program. Visit vchealthcareplan.org/members/memberIndex.aspx, and on the right side of the site, click “Request Case Management or Disease Management”. You will be prompted to enter member specific information. You will then submit this form to a secure email. A nurse will evaluate your request and call you within 2 business days.
REQUEST Case Management or Disease Management
If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
COMBATTING RESPIRATORY INFECTIONS:
THE POWER OF ANTIBIOTIC AWARENESS
We care about your health and want to ensure you receive the most appropriate care for respiratory infections like acute bronchitis and bronchiolitis. Did you know that antibiotics are not always the best solution for these conditions? In fact, using antibiotics when they are not needed can lead to antibiotic resistance and potential side effects. According to the Centers for Disease Control and Prevention (CDC), most cases of acute bronchitis and bronchiolitis are caused by viruses, not bacteria, making antibiotics ineffective. Our goal is to improve your care and avoid unnecessary antibiotic use.
So, if you or a loved one experience symptoms like coughing, chest congestion, or mild difficulty breathing, don’t rush for antibiotics. Instead, reach out to your healthcare provider. They can help determine the best course of action for your specific case, which may include rest, fluids, and other supportive measures.
Let’s work together to combat respiratory infections wisely, preserving antibiotics for when they are truly needed. By doing so, we can protect ourselves and future generations from the threat of antibiotic resistance.
References:
Centers for Disease Control and Prevention (CDC). (2024). Acute Bronchitis: cdc.gov/acute-bronchitis/about/index.html
National Institute for Health and Care Excellence (NICE). (2021). Bronchiolitis in Children. Diagnosis and Management: nice.org.uk/guidance/ng9
TAKING THE RIGHT STEPS FOR UPPER RESPIRATORY INFECTIONS
When it comes to upper respiratory infections (URIs), receiving the appropriate treatment is essential for your health and well-being. URIs, such as the common cold and flu, are usually caused by viruses and do not require antibiotics. Did you know that taking antibiotics when they are not needed can lead to antibiotic resistance and potential side effects?
At Ventura County Health Care Plan, we are committed to providing you with the best care possible. If you or your family members experience symptoms like a runny nose, sore throat, or cough, it’s crucial to consult with your healthcare provider. They can assess your condition and recommend the most suitable course of action, which may include rest, hydration, and over-the-counter medications for symptom relief.
Remember, antibiotics are powerful medications that should only be used when necessary to treat bacterial infections. By working together and avoiding unnecessary antibiotic use, we can protect ourselves and preserve the effectiveness of antibiotics for future generations. Let’s take the right steps for upper respiratory infections and prioritize your health and well-being.
References:
Centers for Disease Control and Prevention (CDC). (2024). About Common Cold. cdc.gov/common-cold/about/
Centers for Disease Control and Prevention (CDC). (2024). Manage Common Cold. cdc.gov/common-cold/treatment/index.html
THROAT INFECTIONS: CHOOSING WISELY FOR YOUR HEALTH
When you or your loved ones experience a sore throat, it’s essential to seek the right care to ensure a swift and accurate diagnosis. Pharyngitis, commonly known as a sore throat, can have various causes, including viral and bacterial infections.
Did you know that not all sore throats require antibiotics?
According to leading healthcare organizations like the American Academy of Family Physicians (AAFP) and the Centers for Disease Control and Prevention (CDC), most sore throats are caused by viruses, and antibiotics won’t help in these cases. Inappropriately prescribed antibiotics can lead to antibiotic resistance and potential side effects.
Our focus is on providing you with the best care possible, which means making informed decisions about when antibiotics are necessary. If you or your loved ones have a sore throat, we encourage you to consult
with your healthcare provider. They will conduct appropriate testing, like a rapid strep test, to determine if your sore throat is caused by bacteria. If it’s viral, your provider will recommend supportive care to help manage your symptoms.
Together, let’s choose wisely for your health and ensure that antibiotics are reserved for situations where they are most effective. By doing so, we protect ourselves, our community, and the effectiveness of these essential medications.
References:
American Academy of Family Physicians (AAFP). (2024). Sore Throat. familydoctor.org/condition/sore-throat
Centers for Disease Control and Prevention (CDC). (2024). Clinical Guidance for Group A Streptococcal Pharyngitis. cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
Flu Vaccine
Influenza is a contagious illness caused by the flu virus. The flu can cause mild to severe illness, and at times can lead to death. That is why it is recommended that everyone 6 months and older get a flu vaccine every year (unless told otherwise by your physician). Flu vaccines will provide protection against three (trivalent vaccine) or four (quadrivalent vaccine) flu viruses and will be available in the fall throughout Ventura County at pharmacies, grocery stores, and other locations.
The best way in protecting yourself against the flu virus is getting the flu vaccine each year. It can be taken simultaneously with other vaccines, including COVID-19. Members 65 years of age or older are encouraged to get a high dose quadrivalent flu shot by the Ventura County Public Health. The high dose vaccine has four times the amount of potency and is recommended for seniors with a lower immune response to vaccination and are at a particular risk for experiencing significant and negative outcomes from a flu infection.
The Ventura County Health Care Agency offers several options on where to obtain your vaccine such as Ventura County Health Care Agency Ambulatory Care Clinics, Ventura County Public Health Immunization Program at Community Clinics and at Community Events.
Common symptoms of the flu are:
• Fever
• Chills
• Cough
• Sore throat
• Runny or stuffy nose
• Muscle or body aches
• Headaches
• Fatigue
• Some people may have vomiting and diarrhea, more common in children than adults
To receive your flu vaccine, visit your primary care physician. Other resources include Ventura County Public Health at Influenza (Flu) - Ventura County Public Health vchca.org/public-health/disease-information/flu .
References:
Centers for Disease Control and Prevention. Key Facts About Influenza (2024). cdc.gov/flu/about/keyfacts.htm
Ventura County Public Health. Influenza (2024). vchca.org/public-health/disease-information/flu
CHOOSING THE RIGHT APPROACH
When it comes to managing low back pain, choosing the right approach is crucial for your well-being. Low back pain can be caused by various factors, and not all cases require imaging studies, such as X-rays, MRIs, or CT scans.
Did you know that most low back pain cases can be diagnosed and treated without the need for imaging?
At Ventura County Health Care Plan, we prioritize your health and aim to provide the most appropriate care. It is essential to understand that imaging studies may not always be necessary for low back pain and can lead to additional costs and potential risks. Instead, your healthcare provider will likely perform a thorough evaluation, considering your medical history, symptoms, and physical examination. We encourage you to have an open conversation with your provider about your low back pain symptoms. Together, you can make informed decisions about the best course of action, which may involve non-invasive treatments like physical therapy, exercise, and pain management strategies.
Let’s work together in making informed decisions about your low back pain care and prioritize your well-being.
References:
1. American Academy of Family Physicians (AAFP). (2023). Low Back Pain. familydoctor.org/condition/low-back-pain/
2. The American College of Physicians (ACP). (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline. acpjournals.org/doi/10.7326/M16-2367
Preventive Health Guidelines
The 2023-2024 Preventive Health Guidelines is an excellent resource where members can find immunization schedules, preventive health screening information, and an adult preventive care timeline. The Preventive Health Guidelines include information from VCHCP, US Preventive Services Task Force (USPSTF), Centers for Disease Control (CDC), and the Agency for Healthcare Research and Quality (AHRQ) and are updated annually. Providers and members are given access to the Preventive Health Guidelines online at: vchealthcareplan.org/members/docs/healthEducationInfo/preventiveHealthGuidelinesCommercial.pdf
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies.
Child Immunizations
Contact your VCHCP Primary Care Provider to discuss the vaccination that is appropriate for your child.
VACCINES PREVENT DISEASE IN PEOPLE WHO OBTAIN THEM and protect those who come into contact with unvaccinated individuals. Vaccines are responsible for the control of many communicable diseases that were once widespread in this country, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, and Haemophilus influenza type b (Hib). Before vaccines, many children died from diseases that vaccines now inhibit, such as whooping cough, measles, and polio. Those same germs exist today, but babies are now protected by vaccines, so we do not see these diseases as frequently. Immunizing individual children also improves the wellbeing of our community, especially those people who are not immunized. People who are not immunized include those who are too young to be vaccinated, those who cannot be vaccinated for medical reasons (example: children with leukemia), and those who cannot make a satisfactory response to vaccination. This information about child immunizations can be found by visiting the VCHCP’s website at vchealthcareplan.org/members/docs/healthEducationInfo/preventiveHealthGuidelinesCommercial.pdf#page=2
Adult Preventive Care
Contact your VCHCP Primary Care Provider to make an appointment for your preventive care visit and to discuss the preventive care services that are appropriate for you. You may also see this information about Adult Preventive Health Visits/Care and a detailed list of vaccinations for adults in the Plan’s Preventive Health Guidelines brochure. To view the brochure, please visit the VCHCP website at: vchealthcareplan.org/members/docs/healthEducationInfo/preventiveHealthGuidelinesCommercial.pdf#page=6
Breast Cancer Screening
You may also see this information about Breast Cancer Screenings in the Plan’s Preventive Health Guidelines brochure. To view the brochure, please visit the VCHCP website at: vchealthcareplan.org/members/docs/healthEducationInfo/preventiveHealthGuidelinesCommercial.pdf#page=6
Contact one of the following providers to discuss the care that is appropriate for you: Your VCHCP Primary Care Provider | Your VCHCP OB/GYN Provider
KEY FACTS:
• Mammograms can find breast cancer early, when it’s easier to treat.
• Most breast lumps are not caused by cancer; many conditions can cause them.
• Breast cancer symptoms vary, and some women don’t have symptoms.
• Men can get breast cancer, but it is not very common. For every 100 cases of breast cancer, less than 1 is in men.
PREVENTION TIPS:
• Keep a healthy weight and exercise regularly.
• Limit the amount of alcohol you drink.
• If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks and find out if it is right for you.
• Know your family history of breast cancer. If you have a close relative with breast cancer, ask your doctor how you can manage your risk.
• A mammogram can’t prevent breast cancer, but it can help find it early. Talk to your health care provider about whether screening is right for you.
Content source: Centers for Disease Control and Prevention
• Breast cancer screening means checking a woman’s breasts for cancer before she has any symptoms. A mammogram is an X-ray picture of the breast. Mammograms are the best way to find breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms.
• Most women who are 50 to 74 years old should have a screening mammogram every two years. If you think that you may have a higher risk of breast cancer, ask your doctor when to have a screening mammogram.
EARLY DETECTION IS THE BEST PRACTICE AGAINST CANCER, ESPECIALLY BREAST CANCER.
In an effort to increase awareness, VCHCP sent mammogram post cards to those who are due for their breast cancer screening. The postcards were mailed in August and again in October 2024. Our goal is to provide education to you to complete this important screening.
You may bring this postcard to your doctor during your office visit to discuss more about your breast cancer screenings.
If you have any questions or concerns, please contact our Health Services Department at (805) 981-5060.
You can now set an appointment for a screening mammogram directly with any VCHCP contracted radiology facility without a doctor’s prescription or order. There is no copay for screening mammogram at any of these contracted facilities. The hours and capacity may vary per location, please make sure to call ahead and make an appointment.
GET YOUR SCREENING MAMMOGRAM DONE WHEN RECOMMENDED.
VCHCP and the U.S. Preventive Services Task Force recommends a screening mammogram every two years between the ages of 40 and 74.
Note: If you are having a diagnostic mammogram, copayment applies.
Bring this card with you to your
BREAST CANCER
BIOMARKER TESTING
VCHCP covers biomarker testing and does not require prior authorization (as mandated by SB535) for an enrollee with advanced or metastatic stage 3 or 4 cancer; and cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer, effective July 1, 2022. Providers must provide applicable cancer or history of cancer diagnosis codes in the primary/principal position on the claim:
• Cancer diagnosis codes: C00 through C96.Z
• History of cancer diagnosis code: Z85 through Z85.9
VCHCP covers biomarker testing as mandated by SB496. This bill would require a health care service plans on or after July 1, 2024, to provide coverage for medically necessary biomarker testing, as prescribed, including whole genome sequencing, for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee’s disease or condition to guide treatment decisions. Prior authorization is required.
The bill requires the Plans, on or after July 1, 2024, to cover biomarker tests that meet any of the following:
• A labeled indication for a test that has been approved and cleared by the FDA or is an indicated test for an FDA-approved drug.
• A national coverage determination made by the Centers for Medicare and Medicaid Services.
• A local coverage determination made by a Medicare Administrative Contractor for California.
• Evidence-based clinical practice guidelines, supported by peer-reviewed literature and peerreviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
PROCEDURE
1. SB 535 Biomarker for advanced cancer includes CPT code range of 81400-81408.
2. SB 496 Biomarker includes but is not limited to these CPT codes:
0062U – IgG and IgM analysis of 80 biomarkers of systemic lupus erythematosus in serum
0310U– Analysis of 3 biomarkers (NT-proBNP, C-reactive protein and T-uptake) for Kawaski disease in plasma specimen
3. Please refer to the Plan’s Utilization Management Policy & Procedure: Treatment Authorization Request Authorization Process and Timeline Standards to address compliance with Health and Safety Code Section 1363.5. The Plan’s Member and Provider Newsletters direct providers and members to the Plan’s website on how to access Plan’s criteria/ guidelines and policies.
Click Treatment Authorization Request: Authorization Process and Timeline Standards for further information.
4. Please refer to the Plan’s Utilization Management Policy for Appeals to address compliance with Health and Safety Code Section 1367.667. The Plan’s Member and Provider Newsletters direct providers and members to the Plan’s website on how to access Plan’s criteria/guidelines and policies.
Click here to learn more about the UM Management Policy for Appeals.
coloring
Practice mindfulness and destress with
Coloring is a healthy way to relieve stress. It can help the body relax and calm your mind. Here are some additional ways to help manage stress:
1. Enjoy simple pleasures Look for opportunities to do things you enjoy, even if it’s just for 1 5 minutes every day. 2. Use positive selft alk Fr ame your thinking around success, rather than failur e.
3. Let things go Some things aren’t worth sweating ove r . Reward yourself for a meaningful accomplishment — instead of being hard on yourself for not getting ever y thing done.
4. T ake a break from t he situation Go for a walk or take three to five deep breaths to help clear your head.
Sources: Mayo Clinic Health System. Coloring is good for y our health American Heart Association. Four ways to deal with stress. Centers for Disease Control and Prevention. Injury prevention a nd control. Coping with stress. Helpguide.org. Stress management: How to reduce, prevent and co pe with stress. National Institute of Mental Health. Fact sheet on stress. This program should not be used for emergency or urgent care needs. In an emergency, call 911 if you are in the United States, the local emergency services phone number if you are outside the United States, or go to the nearest ambulatory and emergency room facility. This program is not a substitute for a doctor’s or professional’s care. Due to the potential for a conflict of interest, legal consultation will not be provided on issues that may involve legal action against Optum or its affiliates, or any entity through which the caller is receiving these services directly or indirectly (e.g., employer or health plan). This program and all its components, in particular services to family members below the age of 16, may not be available in all locations and is subject to change without prior notice. Experience and/or educational le vels of Employee Assistance Program resources may vary based on contract requirements or country regulatory requirements Cover age exclusions and limitations may apply.
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Best Foods For You: Healthy Snack Choices
Best Foods For You: Healthy Snack Choices
Healthy Snack Choices
Healthy Snack Choices
When you choose to snack, think of it as a way to fit in more veggies, fruits, whole grains, and healthy fats. These foods can fill you up and give you an energy boost.
When you choose to snack, think of it as a way to fit in more veggies, fruits, whole grains, and healthy fats. These foods can fill you up and give you an energy boost.
Tips
Tips
Follow these tips to plan snacks that will be healthy and satisfying:
Follow these tips to plan snacks that will be healthy and satisfying:
• Watch your portions.
• Watch your portions.
> Use measuring cups and spoons to help.
> Portion out single-use snacks from large bags and boxes to avoid overeating.
> Use measuring cups and spoons to help.
> Portion out single-use snacks from large bags and boxes to avoid overeating.
• Shop for snacks along the perimeter (outside walls) of the store. Skip the candy and chips in the middle aisles.
• Shop for snacks along the perimeter (outside walls) of the store. Skip the candy and chips in the middle aisles.
• Stock up on healthy snacks so you have them on hand and keep them visible in the front of the pantry and refrigerator.
• Stock up on healthy snacks so you have them on hand and keep them visible in the front of the pantry and refrigerator.
Healthy Snack Ideas
Healthy Snack Ideas
Low Carbohydrate (less than or equals 5 grams)
Low Carbohydrate (less than or equals 5 grams)
> 3/4 cup of light popcorn
> 3/4 cup of light popcorn
> 10 goldfish crackers
> 10 goldfish crackers
> 1 cup raw veggies (carrots, celery, cucumbers)
+ 1 tablespoon dressing or dip
> 1 cup raw veggies (carrots, celery, cucumbers)
+ 1 tablespoon dressing or dip
> 1 hard-boiled egg
> 1 hard-boiled egg
> 1 string cheese stick
> 1 string cheese stick
> 1 frozen sugar-free popsicle
> 1 frozen sugar-free popsicle
> 1 cup of sugar-free gelatin
> 1 cup of sugar-free gelatin
Wellness Programs
Ventura County Health Care Plan provides support and information to promote our members healthy living. To assist in meeting your wellness goals, VCHCP has identified self-management tools for members use. The links below connect to tools and resources to help you live well and take care of yourself. We encourage you to take advantage of these tools to help set your health and wellness goals, then work toward them. If you have any questions, please contact Jennylyn Regacho, QA nurse at (805) 981-5391.
Mental Health Conditions: Depression and Anxiety cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html
FIND A REASON TO QUIT
Do you want to breathe easier? Be around longer for your family? Save money? Whatever gets you fired up, write it down. A strong reason can get you started. And it will help you stay quit when you’re tempted to smoke.
MAKE A PLAN
Think about what triggers you to smoke. Is it stress? Being around smokers? Alcohol? Or something else? Plan to get through those times without smoking. Keep your hands busy and your mind off cigarettes. Examples: drink water, wash the dishes, talk to a nonsmoker.
CALL 1-800-NO-BUTTS
People who call the Helpline are twice as likely to quit for good. A trained counselor will help you make a personal plan and offer support along the way. It’s free, and it works!
GET SUPPORT
Research shows that support while quitting can really help. Talk with your family and friends about your plan to quit. Let them know what they can do to help you.
USE A QUITTING AID
Quitting aids, like nicotine patches and gum, and other FDA-approved medications are helpful. They can cut withdrawal symptoms and increase your chance of quitting for good. Your health plan or Medi-Cal benefits may cover these products. Talk with your doctor about which quitting aids are right for you.
MAKE YOUR HOME & CAR SMOKE-FREE
Having smoke-free areas can help you stop smoking. And your friends and family will enjoy cleaner air and a longer, happier life - with you still in it!
SET A QUIT DATE
Choose a date when you will quit. This shows you’re serious. And you’re more likely to give it a try.
QUIT ON YOUR QUIT DATE
Sounds obvious, right? But what good is a quit date unless you actually try to stop smoking? Planning is good, doing is even better.
PICTURE BEING A NONSMOKER
After you quit, you have a choice to make. Are you a smoker who’s just not smoking for now? Or are you a nonsmoker? For nonsmokers, smoking is not an option in any situation. Choose to see yourself as a nonsmoker.
KEEP TRYING
Most people try several times before they quit for good. Slips don’t have to turn into relapses - but if they do, remember each time brings you closer to your goal.
2024 QUALITY IMPROVEMENT Program Evaluation
Each year, the Health Plan evaluates its success in accomplishing identified goals for the prior year, including, but not limited to, its ability to meet regulatory standards specified by the Department of Managed Health Care (DMHC). For 2023, the Plan is pleased to share that it succeeded in achieving multiple identified goals.
To view the summary of our Quality Improvement Program Evaluation, please click this link: vchealthcareplan.org/members/docs/AnnualQualityAssuranceProgramOverview.pdf
Nondiscrimination
VCHCP complies with applicable Federal and California laws and does not exclude people or otherwise discriminate against them because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability.
The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) enforces certain Federal civil rights laws that protect the rights of all persons in the United States to receive health and human services without discrimination based on race, color, national origin, disability, age, and in some cases, sex and religion.
If you have any questions, or need help to file your complaint, call OCR (toll-free) at (800)-368-1019 (voice) or (800-537-7697) (TDD), or visit their website at: hhs.gov/ocr
You may also send an email to OCRMail@hhs.gov
Milliman Care
Guidelines & Medical Policy Updates
If you believe that you have been discriminated against you may file a complaint with the Office for Civil Rights (OCR). You can file your complaint by email at OCRcomplaint@hhs.gov, or you can mail your complaint to:
Centralized Case Management Operations
U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F HHH Bldg. Washington, D.C. 20201
VCHCP Utilization Management uses Milliman Care Guidelines 28th Edition, VCHCP Medical Policies and VCHCP Prior Authorization Drug Guidelines as criteria in performing medical necessity reviews. Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, but a hard copy of an individual guideline can be provided as requested.
A complete listing of new and updated VCHCP medical policies and prescription drug policies are posted on The Plan’s website at: vchealthcareplan.org/providers/medicalPolicies.aspx
To obtain printed copies of any of our VCHCP Medical/Drug Policies or Milliman Care Guidelines, please contact Member Services at (805) 981-5050 or at (800) 600-8247.
2024 HEDIS
RESULTS FROM MEASUREMENT YEAR 2023 AND INTERVENTIONS
We are delighted to share the exceptional results of Ventura County Health Care Plan (VCHCP) in the 2024 HEDIS measures, based on data from Measurement Year 2023. Our dedication to excellence is evident in various key areas, including preventive screenings for breast cancer, colorectal cancer, and cervical cancer, as well as appropriate childhood immunizations. By meeting these measures, we work together to reduce disease and complications, ensuring better health outcomes for all our members.
Celebrating 2024 Accomplishments
The past year saw remarkable improvements in several areas, such as weight assessment for children and adolescent, adolescent immunizations, cervical cancer screening, colorectal cancer screening, chlamydia screening, hbA1c testing for diabetics, antidepressant medication management, asthma medication ratio, and timely postpartum care. Our Diabetes Disease Management Program has played a pivotal role in providing personalized health coaching calls to members with moderate to high risk. By working together, we have seen significant improvements in compliance with HgbA1c testing and risk reduction.
Setting Our Sights on 2024 Goals
As we look to the future, VCHCP is committed to enhancing our healthcare services further. In 2024, we aim to focus on the following crucial areas:
1. Breast Cancer Screening: Encouraging all women aged 50-74 to receive a screening mammogram every two years.
2. Colorectal Cancer Screening: Ensuring all men and women aged 45-75 receive timely screenings based on recommended intervals.
3. Postpartum Care: Supporting new moms with postpartum visits within 7-84 days of delivery.
4. Controlling High Blood Pressure: Assisting members diagnosed with hypertension to maintain blood pressure levels below 140/90.
5. Comprehensive Diabetes Care: Continuously improving diabetes care for better health management.
Working Together for Improvement
Our journey to success would not be possible without the active participation of our members. To achieve our goals in 2024, we continue to implement a range of interventions, including personalized outreach for preventive health screenings, postcard reminders for breast cancer screenings, health coaching calls and mailed resources for diabetics, follow-up care letters for new moms, and birthday cards with care gap information.
Partnering for a Healthier Future
At VCHCP, we believe that your health journey is a partnership between you, your Primary Care Physician, and our dedicated HEDIS team. By fulfilling these important HEDIS measures, you are taking charge of your health and contributing to a stronger and healthier community.
If you have any questions about the services you may need, we encourage you to reach out to your primary care physician. For inquiries related to HEDIS, please contact VCHCP at (805) 981 5060 .
Together, let’s continue striving for excellence and building a healthier future for all.
SURVEY RESULTS
MEMBER SATISFACTION WITH Utilization Management
As part of our continuing commitment to serve our members, VCHCP conducted a 2023 Consumer Assessment of Healthcare Providers and System (CAHPS) survey. The purpose of this survey is to measure how well the Health Plan meets members’ expectations and goals. SPH Analytics was selected by VCHCP to randomly select eligible members to participate in the survey using a combination of mail and telephone outreach.
We would like to thank the 149 members who responded to our survey, yielding a 13.59% response rate. Based on your responses, specifically with regards to your “experience with our Utilization Management” (UM), the Plan is committed to improving member survey results and experiences. The specific questions in the survey that pertain to your experience with our Utilization Management are:
Q 9: IN THE LAST 12 MONTHS , how often was it easy to get the care, tests, or treatment you needed?
Q 20: IN THE LAST 12 MONTHS , how often did you get an appointment to see a specialist as soon as you needed?
We heard your feedback and recognized we have opportunities for improvement. We have continued these actions to improve your experience with our Utilization Management such as:
Telemedicine (Teladoc) which helped with access issues.
Direct Specialty Referral Program for our VCHCP health plan members.
The Primary Care Physicians can directly refer members to certain in network/contracted specialty providers without requiring prior authorization.
Evaluating and removing prior authorization requirement on services that the Plan generally approve, reducing the barrier of having to obtain prior authorization.
The intent is to make it easy for members to get these services.
Working with its contracted providers to send timely referrals to the Plan to ensure timely processing of prior authorization requests.
Continuing efficiencies in prior authorization processing.
Electronic prior authorization referral process at the Ventura County Medical Center (VCMC) through the Cerner system.
Addressing access issues for continued improvement with collaboration between the Plan and providers.
Executing contracts with needed specialists in geographic areas of need.
Monitoring the timeliness of our UM prior authorization processing daily to ensure timely review and compliance with regulatory requirements. So far in 2024, over 98% of requests received have been completed within the specified regulatory requirement.
Your continued participation in our annual member satisfaction surveys and other feedback will help us identify areas of opportunity for improvement, which in turn aids us in increasing the quality of care you receive.
Thank you again for your participation.
New Medical Technology
VCHCP’S MEDICAL DIRECTOR , or designee, evaluates new technology that has been approved by the appropriate regulatory body, such as the Food and Drug Administration (FDA) or the National Institutes of Health (NIH). Scientific evidence from many sources, specialists with expertise related to technology and outside consultants when applicable are used for the evaluation. The technology must demonstrate improvement in health outcomes or health risks, the benefit must outweigh any potential harm and it must be as beneficial as any established alternative. The technology must also be generally accepted as safe and effective by the medical community and not investigational.
For help with new medication evaluations, the Plan looks to our Pharmacy Benefit Manager, Express Scripts, for their expertise. For new behavioral health procedures, the Plan uses evaluations done by our Behavioral Health delegate, OptumHealth Behavioral Solutions of California (also known as Life Strategies).
Once new technology is evaluated by the Plan, the appropriate VCHCP committee reviews and discusses the evaluation and makes a final decision on whether to approve or deny the new technology. This final decision may also determine if any new technology is appropriate for inclusion in the plan’s benefit package in the future.
FOR ANY QUESTIONS, PLEASE CONTACT THE VCHCP Utilization Management Department at (805) 981-5060 .
PHARMACY UPDATES
Ventura County Health Care Plan updates the formulary with changes and gets re-posted monthly on the VCHCP’s member website. Here is the direct link of the electronic version of the formulary posted on the Ventura County Health Care Plan’s website: vchealthcareplan.org/providers/docs/padg/NationalPreferredFormulary.pdf
A list of additions and deletions for the Ventura County Health Care Plan’s formulary was recently approved by the Plan’s Pharmacy & Therapeutics Committee and can be found by visiting the Plan’s website at vchealthcareplan.org/members/programs/docs/ProviderNotificationAddsAndDeletes.pdf.
Additional information regarding the National Preferred Formulary is available thru Express Scripts (ESI) at express-scripts.com . Logging in is required.
Note: The Plan’s Drug Policies, updated Step Therapy, Drug Quantity Limits, and Preferred Medication list can be accessed at VCHCP’s website - Member page under the “Preferred Medications List” and “Prior Authorization Drug guidelines”: vchealthcareplan.org/providers/providerIndex.aspx
Plan’s Drug Policies - vchealthcareplan.org/providers/priorAuthDrugGuidelines.aspx
Preferred Medications list vchealthcareplan.org/members/programs/docs/ProviderDrugList.pdf
A member or a member’s designee can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization, by submitting an exception via online request available in the VCHCP member website (vchealthcareplan.org/members/requestPharmacyExceptionForm.aspx) or by calling the Plan at (805) 981-5060
To access the policy and procedure for the Drug benefit Program of VCHCP, please click this link vchealthcareplan.org/members/programs/docs/ PrescriptionMedicationBenefitProgramDescription.pdf
2024 National Preferred Formulary Exclusions
The excluded medications are not covered by the National Preferred Formulary beginning January 1, 2024, unless otherwise noted. Please note that members filling prescriptions for one of these excluded drugs may pay the full retail price. Please discuss the alternative preferred medications with your patients and provide a new prescription for one that you feel is right for the patient. To access the list of National Preferred Formulary Exclusions, please visit our website at 2024 Express Scripts National Preferred Formulary Exclusions (vchealthcareplan.org).
VCHCP NETWORK
NEW TO THE NETWORK
Abigail Nimz, M.D., an OB/GYN at Mandalay Bay Women & Children’s Medical Group (VCMC) in Oxnard and Sierra Vista Family Medical Clinic (VCMC) in Simi Valley, has been added February 2024.
Alexis Kerl, M.D., a Family Medicine physician at Alta California Medical Group in Simi Valley, has been added effective August 2024.
Ashley Netrow, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., Ojai Valley Community Health Center in Ojai, has been added effective February 2024.
Avan Patel, M.D., an Internal Medicine physician at Dignity Health Medical Group Ventura County in Camarillo, has been added effective July 2024.
Calvin Lin, M.D., a Pediatrician at Lilia Fernandez Coppa, M.D., in Oxnard, has been added effective July 2024.
Carina Rodelo, P.A.-C., a Physician Assistant at Dignity Health Medical Group Ventura County in Ventura, has been added effective May 2024.
Chase Diego, P.A.-C., a Physician Assistant at California Dermatology Institute in Oxnard and Thousand Oaks, has been added effective May 2024.
Christopher Dru, M.D., a Urologist at Anacapa Urology Clinic (VCMC) in Ventura, has been added effective January 2024.
Daniel Lopez, M.D., an OB/GYN at Clinicas Del Camino Real Inc., in Oxnard, has been added effective April 2024.
Elida Gonzalez, P.A.-C., a Physician Assistant at California Dermatology Institute in Thousand Oaks, has been added effective July 2024.
Elizabeth Hoffman, R.D.N., a Registered Dietician Nutritionist at 360 Nutrition Consulting in Camarillo, has been added effective May 2024.
Esther Opoku, P.A.-C., a Physician Assistant at Clinicas Del Camino Real Inc., in Camarillo, has been added effective July 2024.
Hannah Saroka, R.D.N., a Registered Dietician Nutritionist at 360 Nutrition Consulting in Camarillo, has been added effective May 2024.
For a full list of participating providers please see our website: vchealthcareplan.org/members/physicians.aspx or contact Member Services at (805) 981-5050 or (800) 600-8247
Irish Dawn Dorsey, P.A.-C., a Physician Assistant at Matthew L. Bloom, D.O., PC, in Ventura, has been added effective March 2024.
Jacqueline Shellito, M.D., an OB/GYN at Sierra Vista Family Medical Clinic (VCMC) in Simi Valley, has been added effective December 2023.
Jennifer King, M.D., a Maternal & Fetal Medicine specialist at Obstetrix Medical Group of the Central Coast in Thousand Oaks and Ventura, has been added effective July 2024.
Jerome De Vera, D.O., a Pulmonary Disease specialist at Ventura Pulmonary & Critical Care in Ventura, has been added effective July 2024.
Jesselle Grace Carino, N.P., a Nurse Practitioner at Genesis Healthcare Partners in Oxnard and Camarillo, has been added May 2024.
Jessica Perez, P.A.-C., a Physician Assistant at Clinicas Del Camino Real Inc., Karen R. Burnham Health Center in Oxnard, has been added effective March 2024.
Jia Ding, M.D., a Maternal & Fetal Medicine specialist at Mandalay Bay Women & Children’s Medical Group (VCMC) in Oxnard, has been added effective August 2024.
John Ippolito, M.D., a Family Medicine physician at Rose Avenue Family Medical Group in Oxnard, has been added effective May 2024.
Joshua Hedaya, M.D., an Ophthalmologist at Miramar Eye Specialists in Simi Valley, Thousand Oaks and Westlake Village, has been added effective July 2024.
Justin Mikesell, P.A.-C., a Physician Assistant at Pacifica Center For Dermatology in Camarillo, has been added effective April 2024.
Karyn Teel, M.D., an Ophthalmologist at Miramar Eye Specialists in Camarillo, Oxnard and Ventura, has been added effective April 2024.
Kelly Calkins, P.A.-C., a Physician Assistant at Dignity Health Medical Group Ventura County in Camarillo, has been added effective July 2024.
Kelsi Rau, N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., in Camarillo, has been added effective April 2024.
Kenneth Leong, M.D., a Plastic and Hand Surgeon at Anacapa Plastic, Reconstructive, and Hand Surgery (VCMC) in Ventura, has been added effective March 2024.
Kevin Shin, D.O., a Family Medicine physician at Clinicas Del Camino Real Inc., La Colonia in Oxnard, has been added effective May 2024.
Kevin Westbrook, M.D., a Family Medicine physician at Alta California Medical Group in Simi Valley, has been added effective August 2024.
Lilia Coppa, M.D., a Pediatrician at Lilia Fernandez Coppa, M.D., in Oxnard, has been added July 2024.
Madison Sweet, M.D., a Pulmonary Disease specialist at Ventura Pulmonary & Critical Care in Ventura, has been added effective July 2024.
Manja Perilla, F.N.P., a Nurse Practitioner at Magnolia Family Medical Center (VCMC) in Oxnard, has been added effective February 2024.
Michael Benjamin, M.D., a Hematology/ Oncology specialist at Regatta Health in Simi Valley, has been added effective June 2024.
MiniMed Distribution Corp., a Durable Medical Equipment supplier, has been added effective July 2024.
Naasir Lakhani, M.D., a Family Medicine physician at Clinicas Del Camino Real Inc., El Rio in Oxnard, has been added effective May 2024.
Paramjit Singh, D.O., a Rheumatologist at Conejo Valley Family Medical Group (VCMC) in Thousand Oaks and Magnolia Family Medical Center (VCMC) in Oxnard, has been added effective January 2024.
Paul Johnson, M.D., a Family Medicine physician at Santa Paula Medical Clinic (VCMC), has been added effective May 2024.
POW Physical Therapy, a Pelvic Physical Therapist and Electromyography (EMG)/Nerve Conduction Study facility, has been added effective August 2024.
Robert Sogomonian, M.D., a Cardiovascular Disease specialist at Cardiology Associates Medical Group in Oxnard and Ventura, has been added effective July 2024.
Rukmini Enjamuri, M.D., a Gastroenterologist at Genesis Healthcare Partners in Camarillo and Oxnard, has been added effective February 2024.
Sahil Vohra, D.O., an Orthopedic Surgeon at West Ventura Orthopedics and Podiatry Clinic (VCMC) in Ventura, has been added effective December 2023.
Sara San Pedro, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., in Ventura, has been added effective July 2024.
Saranya Reghunathan, M.D., an Otolaryngologist at Advanced ENT & Voice Center in Camarillo, has been added effective July 2024.
Soledad Contreras Barrera, P.A.-C., a Physician Assistant at Anacapa Neurosurgery (VCMC) in Ventura, has been added effective February 2024.
Stephanie Whittle, M.D., a Family Medicine physician at Clinicas Del Camino Real Inc., in Moorpark, has been added effective April 2024.
Tiffany Loh, M.D., a Dermatologist at Pacifica Center for Dermatology in Camarillo, has been added effective May 2024.
Timothy Chen, M.D., a Family Medicine physician at Clinicas Del Camino Real Inc., El Rio in Oxnard, has been added effective June 2024.
Valerie Ikemefuna, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., in Ventura, has been added effective May 2024.
Virginia Guerrero, F.N.P., a Nurse Practitioner at Renal Consultants of Ventura County in Camarillo and Oxnard, has been added effective June 2024.
Wendy Warwar, M.D., a Pediatrician at Lilia Fernandez Coppa, M.D., in Oxnard, has been added effective July 2024.
LEAVING THE NETWORK
Adnan Ameer, M.D., a Gastroenterologist at Island View Gastroenterology Associates in Ventura, has left effective December 2023.
Anne Rodriguez, M.D., a Gynecological Oncologist at Community Memorial Gynecologic Oncology in Ventura, has left effective June 2024.
Avan Patel, M.D., an Internal Medicine physician at Alamar Healthcare in Camarillo, has left effective June 2024.
Benjamin Dirkx, D.O., a Pain Management specialist at Spanish Hills Interventional Pain Specialists in Camarillo, has left effective September 2023.
Brittni Vogel, P.A.-C., a Physician Assistant at Clinicas Del Camino Real Inc., Ojai Valley Community Health Center, has left effective June 2024.
Celeste Cole, P.A.-C., a Physician Assistant at Cardiology Associates Medical Group in Oxnard and Ventura, has left effective February 2024.
Chris Wu, M.D., an Ophthalmologist at California Retina Consultants in Oxnard, Simi Valley and Westlake Village, has left effective May 2024.
Christopher Tatum, D.P.M., a Podiatric Surgeon at Foot and Ankle Concepts in Oxnard, has left effective July 2024.
Emily Ewing, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., La Colonia in Oxnard, has left effective February 2024.
Erin Thompson, P.A.-C., a Physician Assistant at Matthew L. Bloom, DO, PC in Oxnard and Ventura, has left effective July 2024.
Farridah Shafiee, D.O., an Internal Medicine physician at Alta California Medical Group in Simi Valley, has left effective April 2024.
Heidi Miller, D.O., an OB/GYN at Clinicas Del Camino Real Inc., El Rio in Oxnard, has left effective June 2024.
John Huebner, P.A.-C., a Physician Assistant at Dignity Health Medical Group Ventura County in Oxnard, has left effective October 2023.
John Ippolito, M.D., a Family Medicine physician at Moorpark Family Care Center (VCMC), has left effective April 2024.
Jonathan Casillas, P.A.-C., a Physician Assistant at Clinicas Del Camino Real Inc., in Simi Valley, has left effective April 2024.
Justin Mikesell, P.A.-C., a Physician Assistant at California Dermatology Institute in Ventura, has left effective February 2024.
Kelsi Rau, N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., in Camarillo, has left effective June 2024.
Kenisha Thomas, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., La Colonia in Oxnard, has left effective July 2024.
Khyrie Jones, M.D., a Physical Medicine & Rehabilitation specialist at Boomerang Healthcare in Oxnard, has left effective August 2023.
Linda Davila, N.P., a Nurse Practitioner at Sierra Vista Family Medical Clinic (VCMC) in Simi Valley, has left effective July 2024.
Logan Horejsi, P.A.-C., a Physician Assistant at California Dermatology Institute in Ventura, has left effective April 2024.
Mariam Saad, P.A.-C., a Physician Assistant at California Dermatology Institute in Ventura, has left effective September 2022.
Mayce Alkuraishi, M.D., a Pediatrician at Mandalay Bay Women & Children’s Medical Group (VCMC) in Oxnard, has left effective July 2024.
Megumi Sugimoto, M.D., a Family Medicine physician at Clinicas Del Camino Real Inc., in Ventura, has left effective July 2024.
Misty Eleryan, M.D., a Dermatologist at Pacifica Center For Dermatology in Camarillo, has left effective October 2023.
Nada Sarsour, P.A.-C., a Physician Assistant at Ideal Womens Health Specialist in Ventura, has left effective May 2024.
Nika Bagheri, M.D., an Ophthalmologist at California Retina Consultants in Oxnard and Westlake Village, has left effective November 2023.
Priscilla Lee, N.P., a Nurse Practitioner at Conejo Valley Family Medical Group (VCMC) in Thousand Oaks, has left effective April 2024.
Roseann Tibbs, C.N.M., a Certified Nurse Midwife at Ideal Womens Health Specialist in Ventura, has left effective June 2024.
Sarah Roberts, F.N.P., a Nurse Practitioner at Fillmore Family Medical Group (VCMC), has left effective July 2024.
Scott Bourns, D.O., a Family Medicine physician at Clinicas Del Camino Real Inc., in Moorpark, has left effective April 2024.
Scott Chicotka, M.D., a Cardiothoracic Surgeon at California Cardiovascular & Thoracic Surgeons in Ventura, has left effective June 2023.
Shahin Ghadir, M.D., a Reproductive Endocrinologist at Southern California Reproductive Center, has left effective November 2023.
Stephanie Whittle, M.D., a Family Medicine physician at Clinicas Del Camino Real Inc., in Moorpark, has left effective June 2024.
Sydney Tang, P.A.-C., a Physician Assistant at California Dermatology Institute in Ventura, has left effective March 2024.
Thomas Goldschmidt, M.D., an Internal Medicine physician at Magnolia West (VCMC) in Oxnard, has left effective July 2024.
Tipu Khan, M.D., a Family Medicine physician at Academic Family Medicine Center (VCMC) in Ventura, is no longer a PCP effective April 2024.
Wallace Baker, M.D., a Family Medicine physician at Academic Family Medicine Center (VCMC) in Ventura, has left effective March 2024.
William Hogan, M.D., a Gynecological Oncologist at Community Memorial Gynecologic Oncology in Ventura, has left effective December 2023.
CHANGES
California Dermatology Institute has added new service locations in Moorpark and Oxnard, effective June 2024.
Central Coast Center for Gynecologic Oncology has changed their name to Community Memorial Gynecologic Oncology, effective March 2024.
CMH Centers for Family Health in Camarillo, Oxnard and Santa Paula has changed their name to Community Memorial Health Center, effective March 2024.
Dignity Health Medical Group Ventura County has added two new service locations in Camarillo, 64 East Daily Drive effective January 2024 & 5051 Verdugo Way, Suite 100 effective July 2024.
Dignity Health Medical Group Ventura County has added a new service location in Thousand Oaks, effective July 2024.
Dignity Health Medical Group Ventura County in Oxnard has moved suite numbers, effective January 2024.
Los Robles Homecare Services, a Home Health Agency, in Thousand Oaks has moved to a new location in Thousand Oaks, effective February 2024.
Matthew L. Bloom, D.O., PC has added a new service location in Oxnard, effective April 2024.
Mission Hospice of Ventura has moved to a new location in Oxnard, effective February 2024.
Pacific Cardiovascular & Vein Institute has added a new service location in Camarillo, effective June 2024.
Perinatal Diagnostic Center in Thousand Oaks and Ventura are now called Obstetrix Medical Group of the Central Coast, effective March 2024. Locations remain the same.
San Buenaventura Urology has changed their name to Community Memorial Urology, effective March 2024.
Thousand Oaks Dialysis is no longer a contracted site, effective March 2024.
Vista Del Mar Medical Group in Camarillo has moved to a new location in Camarillo, effective March 2024.
STANDARDS FOR MEMBERS’ R ights & R esponsibilities
Ventura County Health Care Plan (VCHCP) is committed to maintaining a mutually respectful relationship with its Members that promotes effective health care. Standards for Members Rights and Responsibilities are as follows:
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Members have a right to receive information about VCHCP, its services, its Practitioners and Providers, and Members’ Rights and Responsibilities.
Members have a right to be treated with respect and recognition of their dignity and right to privacy.
Members have a right to participate with Practitioners and Providers in decision making regarding their health care.
Members have a right to a candid discussion of treatment alternatives with their Practitioner and Provider regardless of the cost or benefit coverage of the Ventura County Health Care Plan
Members have a right to make recommendations regarding VCHCP’s Member Rights and Responsibility policy.
Members have a right to voice complaints or appeals about VCHCP or the care provided.
Members have a responsibility to provide, to the extent possible, information that VCHCP and its Practitioners and Providers need in order to care for them.
Members have a responsibility to follow the plans and instructions for care that they have agreed upon with their Practitioners and Providers.
Members have a responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
For information regarding the Plan’s privacy practices, please see the “HIPAA Letter and Notice of Privacy Practices” available on our website at: vchealthcareplan.org/members/memberIndex.aspx.
Or you may call the Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 to have a printed copy of this notice mailed to you.
