COVID and Flu Updates
Stay Healthy with Flu and COVID Shots
Annual flu and COVID-19 shots are recommended for everyone ages 6 months and older to help reduce the chances of getting sick and being hospitalized, as well as to help protect others in the community. Free flu and COVID shots are available for VHP members at several locations such as:
• Walgreens, Safeway, Costco, and CVS: Schedule an appointment by phone or online in advance. Remember to bring your VHP ID card.
• Valley Medical Center Pharmacies: Book an appointment online at https://myhealthonline.sccgov.org/ mychartprd/openscheduling.
• Primary Care Physicians: Contact your doctor’s office to see if they offer flu and COVID shots.
For parents of children ages 6 months to 4 years, please contact your pediatrician for vaccine information. If you have any questions about your specific health
conditions and getting vaccines, please contact your primary care physician directly.
If you need assistance, please contact VHP Member Services at 1-888-421-8444 or memberservices@vhp.sccgov.org.
Order Your Free At-Home COVID Tests
The federal government is offering four free at-home COVID-19 test kits to every U.S. household. You do not need to be covered by any insurance plan to be eligible. Order your free at-home test kits from the federal government at www.covidtests.gov. The free test kits are neither provided nor mailed by Valley Health Plan. If you have any questions, please visit www.covidtests.gov.
VHP members may also get at-home COVID tests for free through retail pharmacies or health centers approved by VHP. For questions or assistance, please contact VHP Member Services at 1-888-421-8444 or memberservices@vhp.sccgov.org.
VHP and Virta Health Offer Weight Loss and Diabetes Reversal Program
Valley Health Plan, through a partnership with Virta Health, is now offering our members with type 2 diabetes and prediabetes a weight loss and diabetes reversal program at no additional cost.
On average, Virta members lost 18 pounds in just 10 weeks. 87% of members were able to stop or reduce medications.
Virta offers a nutrition program designed to help members understand their bodies and foods that nourish them. Participants may experience weight loss, lower blood sugar levels, and even the potential to reverse type 2 diabetes.
With a focus on personalized care, Virta’s dedicated team will create a sustainable and enjoyable nutrition plan tailored to individual health goals. Key features of the program include:
• On-demand support from an expert health coach
• A dedicated medical provider to help safely reduce medications
• Exclusive access to nutrition resources and recipes
• A digital weight scale and meter
Valley Health Plan fully covers the cost of Virta (valued at over $3,000) for *you and *your eligible family members with type 2 diabetes or prediabetes.
*Virta is available to members and eligible dependents ages 18+ who are enrolled in a qualifying health plan through VHP. This benefit is currently offered to those with type 2 diabetes and prediabetes, though certain medical conditions may exclude some patients from Virta treatment. Start the application now to find out if you qualify.
Virta provides free language services to people whose primary language is not English. If you need these services, please contact Virta at 1-844-847-8216 or support@virtahealth.com.
Interested in exploring this valuable resource? Join Virta today at: www.virtahealth.com/ join/valleyhealthplan. Para el español: es.virtahealth.com/join/valleyhealthplan.
Join now info.virtahealth.com/vhp-join
Community Resources
The 988 Suicide and Crisis Lifeline Is Available 24/7
If you or someone you know is struggling, the 988 Lifeline is here to help. It is a free, confidential service that connects you with trained counselors, no matter what you are going through. You do not have to be suicidal to reach out. Talking with someone can help save your life. The 988 Lifeline is for anyone facing challenges such as:
• Stress or anxiety
• Economic worries
• Substance use
• Relationship issues
• Intimate partner violence
• Depression
• Culture and identity
• Mental or physical illness
• Loneliness
WHEN TO CALL 988
• Thoughts of suicide
• Having mental health issues or stress
• Worried about the mental well-being of another
• Emotional support
WHEN TO CALL 911
• Imminent danger
• Crime in progress/committed
• Suspicious activity
• Believe someone is in danger
• Police/medical/fire emergency
When you call or text 988 your conversation is confidential, and the support you get is free, anonymous, and available 24/7. Counselors are there to listen, help, and connect you support if needed. If law enforcement or medical emergency response is needed, then the counselor will ask for contact information so responders can help. If you are worried about a loved one or someone else, you can also call 988 on their behalf.
The service is available in over 200 languages, including Spanish, Vietnamese, Chinese, and Tagalog. Texting is available in English and Spanish.
If you are in Santa Clara County and do not have a 408, 650, or 669 area code, you can still reach the local service by calling the County Behavioral Health Services at 1-800704-0900 and pressing 1. This number can also be used for non-emergency calls about mental health and substance use treatment services and referrals.
For more details about the 988 Lifeline, visit www.988lifeline.org. For immediate help, call or text 988. To chat, visit: https://chat.988lifeline.org/.
American Cancer Society Programs and Services
Valley Health Plan has joined forces with the American Cancer Society in the fight against cancer in Santa Clara County through participation in local relay races and donations to their Discovery Shops. The American Cancer Society has many programs and services available for those facing a cancer diagnosis, as well as their families and caregivers. There are resources for every type of cancer and for every phase of the cancer journey including:
• A 24/7 Cancer Helpline staffed by Cancer Information Specialists
• Cancer screening resources with more information about cancer screening, what tests you may be due for, and where you can get screened
• Free rides to and from treatment through their Road to Recovery Program
• Personalized peer-to-peer support through American Cancer Society CARES and the Cancer Survivors Network
• Customized support for breast cancer patients through Reach to Recovery
• A curated collection of quality wigs, headwear, and post-surgical products including bras and breast forms from EverYou
American Cancer Society also has online education materials to help those with cancer and their loved ones better understand prevention and screening, a cancer diagnosis, treatment, and potential side effects.
To learn more about American Cancer Society programs and services, call their 24/7 helpline at 1-800-227-2345 or visit www.cancer.org.
Pharmacy Benefits Information
Real Time Pharmacy Drug Costs
Assembly Bill 2352 requires health plans to provide real-time prescription drug price information to members, allowing them to see the actual cost of a drug before they purchase it. The goal is to help members make more informed decisions about their prescriptions and potentially find more affordable options. This could also include options such as generic drugs or cost-sharing assistance. The bill aims to reduce costs for members.
To get real-time information regarding your pharmacy coverage, including prescription drugs and cost shares, you can access the Navitus Member Portal and register for an account.
The following real-time information is available including:
• General pharmacy benefit information
• Formulary details
• Pharmacy search
• What's my Copay
• Medication history
• Drug search (information about drugs)
• Mail orders
• Initiate request for non-formulary drugs
VHP members can access the Navitus Member Portal and register for an account at: https://memberportal.navitus.com/.
Prescription drugs are an important part of your health, and we want you to understand your benefits. To learn more about pharmacy benefits, covered medications, cost sharing, and the Navitus Member Portal visit: https://www.valleyhealthplan.org/ members/pharmacy.
For more information or general questions, please contact VHP Member Services at 1-888-421-8444 or by email at memberservices@vhp.sccgov.org.
Drug Formulary
The VHP Drug Formulary is a list of covered outpatient drugs. The VHP Pharmacy and Therapeutics (P&T) Committee reviews and updates this list quarterly. They also review procedures once per year.
The P&T Committee decides:
• which drugs to add to the formulary
• which drugs need prior authorization
• if a drug has quantity limits or requires step therapy
• which drugs require therapeutic interchange
• when the use of generic, authorized generic, biosimilar, or interchangeable drug substitutions may be used
• which drugs will not be added
These choices are based on the U.S. Food and Drug Administration approval, scientific articles, and drug safety. Choices are also made based on whether there are drugs available that achieve similar results.
You can visit: www.valleyhealthplan. org/providers/pharmacy at any time to view the drug formulary and summary of
updates. When a negative formulary change occurs that could impact you, VHP will send a communication to you and your doctor.
Prior Authorizations
Sometimes, your doctor might need special approval for a drug. Special approval, or prior authorization, is needed when a drug is not in the Formulary. It is also needed when a drug is on the Formulary with “PA” under the special code column. For approval, your doctor must fill out a “Prescription Drug Prior Authorization” or “Step Therapy Exception Request” form and send it to the pharmacy benefit manager. These forms are reviewed by a pharmacist or a doctor. Approval is based on established criteria and medical necessity.
Your doctor can access information about VHP’s prior authorization criteria by logging into the Navitus Provider Portal with their National Provider Identifiers and selecting, “Valley Health Plan.” VHP Members can request a drug not on the formulary by logging into the Navitus Member Portal with their Member IDs. VHP Members can access the links below:
▪ Navitus Member Portal: https:// memberportal.navitus.com/landing
▪ VHP Website: www.valleyhealthplan. org/providers/pharmacy
Navitus Health Solutions handles the pharmacy benefit on behalf of VHP. This includes customer service, formulary maintenance, prior authorizations, exception to coverage, and drug recall notifications. Navitus Customer Care is available 24/7 at 1-866-333-2757 (toll-free).
Copays
Copays apply to drugs prescribed by an authorized prescriber and dispensed by a Plan Pharmacy. Please refer to the Summary of Benefits and Coverage (SBC) for the copay amount for each tier. An out-of-pocket cost
may apply as described by your Summary of Benefits and Coverage (SBC). For more details, see the “Copays and Deductibles” section.
VHP communicates a summary of the pharmaceutical management procedures, P&T Committee formulary decisions, and negative formulary changes to members and to network providers. This happens at least once a year, when a negative change occurs, and when there are updates. These details are in the formulary, including a list of covered Physician Administered Drugs. They are also posted on the VHP website at www.valleyhealthplan.org.
If you would like a paper copy of any of the formulary management procedures, the VHP formulary, changes to the VHP drug formulary, or if you have questions about the formulary, please contact Navitus Customer Care at 1-866333-2757 (toll-free). Paper copies can be sent by mail, fax, or email. For more information, you can also visit www.valleyhealthplan.org.
If you have questions or need help, please contact VHP Member Services at 1-888-4218444 (toll-free) or memberservices@vhp. sccgov.org.
Health Education and Screenings
Understanding Smoking: Health Risks, Benefits of Quitting, and Support
Smoking & Tobacco Use
Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Smoking and use of tobacco products, including cigarettes, cigars, smokeless tobacco, or other nicotine containing products, cause or worsen many diseases and health conditions.
Health Impacts of Tobacco Use
The health risks associated with tobacco use include cancer, heart disease, and respiratory problems.
Smoking affects every part of your body including ears, nose, lungs, stomach, blood, brain, eyes, mouth, heart, and bones. If you smoke, you are 10 times more likely to get cancer than a person who has never smoked.
Health Benefits of Quitting
Quitting smoking will improve your health and can add up to 10 years to your life. As soon as you quit smoking, your body begins to repair the damage caused by smoking and amazingly continues to repair itself for many years.
Valley Health Plan’s Tobacco Cessation Program
Valley Health Plan’s Health Education Department offers a certified Tobacco Cessation Program to help VHP members quit smoking and using tobacco products.
This program helps identify and address individual triggers and reviews various nicotine replacement therapy (NRT) options, including how to safely use NRT. The goal for this program is to teach members how to successfully quit smoking even if they have attempted to quit in the past. This program is available to VHP members at no cost.
VHP’s Tobacco Cessation Program consists of two individual online sessions. In-person sessions can also be arranged by member request. A certificate of completion will be presented to members who attend both sessions.
Tobacco-certified VHP Health Education Specialists provide direct support to VHP members including:
• Understanding smoking history and routine
• Learning the benefits of quitting and different strategies to quit
• Managing withdrawal symptoms and smoking “triggers”
• Understanding options for nicotine replacement therapy to discuss with their doctors
• Recognizing the importance of selecting a “quit date”
To learn more about VHP’s Health and Wellness programs and how to enroll, visit our website at www.valleyhealthplan. org/members/health-and-wellness.
If you have any questions, please reach out to VHP’s Health Education Department at healtheducation@vhp.sccgov.org or call us at 1-669-220-5235, option 1.
Lead Screenings for Children
Lead is a natural occurring metal that can
cause negative health effects. People are exposed to lead by eating lead paint chips, ingesting contaminated food or water, or by breathing in lead dust. Lead may be still found in and around older homes and buildings, as well as in some consumer products, remedies, and foods.
Even in small amounts, lead has harmful effects on the body. Lead exposure may lead to lifelong learning, behavioral, reproductive, cardiovascular, and other health problems.
Lead poisoning is one of the most common environmental illnesses in California, but it is completely preventable.
Lead poisoning in children
Children younger than 6 years old are more likely to be exposed to lead due to their handto-mouth behavior. Many children ingest lead dust by putting objects such as toys and dirt in their mouths.
Lead can harm your child, making it hard for your child to learn, pay attention, and behave. Most children who have lead poisoning do not look or act sick.
Lead sources that may put your child at risk
• Lead paint inside or outside the home that is chipped, peeling, or damaged in any way. If your home was built before 1978, it may have lead paint.
• Some imported dishes, pots, water crocks, or older dishware, especially if worn, chipped,
or cracked.
• Imported food such as chapulines (fried grasshoppers).
• Brightly colored spices from other countries, such as chili powder, imported tamarind candy, turmeric, and khmeli suneli (dried spice blend).
Tips to protect your child from lead
• Do not let your child chew on painted surfaces or eat paint chips.
• Wash your child’s hand and toys often. Lead dust and dirt can stick to hands and toys that children put in their mouths.
• Avoid giving your child sweets from other countries. Some candies from outside the U.S. have lead in them.
• Keep your home clean and dust-free. This keeps lead in dust and dirt from spreading in the house.
Lead screening for children
Children ages 1 to 2 who are in publicly supported programs*, and all children at risk for lead exposure, should get tested. Children in publicly supported programs* ages 24 months to 6 years should be tested if they were not previously tested.
If you think your child might be at risk of lead exposure, ask your child’s doctor for a blood lead test. The only way to know if your child has lead poisoning is to get a blood test for lead. The cost of lead screening for children is covered by Valley Health Plan.
* Examples of publicly supported programs include Medi-Cal, CHDP, and Women, Infants, and Children (WIC).
Chlamydia Screenings for Women
Chlamydia is the most common, treatable, sexually transmitted infection (STI) in the United States. Chlamydia infections in women
usually do not have signs or symptoms, and they can cause damage to a woman’s reproductive system. This can make it difficult or impossible to get pregnant later. Chlamydia can also cause pelvic inflammatory disease and ectopic pregnancy (pregnancy that occurs outside the womb).
How is chlamydia contracted?
You can get chlamydia by having vaginal, anal, or oral sex with someone who has chlamydia. A pregnant person with chlamydia can give the infection to their baby during childbirth.
How can you reduce your risk?
The only way to completely avoid STIs is to not have vaginal, anal, or oral sex. If you are sexually active, the following things can lower your chances of getting chlamydia:
• Being in a long-term mutually monogamous relationship with a partner who has been tested and does not have chlamydia
• Using condoms every time you have sex
Chlamydia screenings for women
Chlamydia screening is recommended for sexually active women including those who are pregnant without signs and symptoms of chlamydia if they are:
• 24 years or younger
• 25 years or older who are at increased risk for infection
Women 25 years or older are at increased risk if they have:
• A previous or existing STI
• A new or more than one sex partner
• A sex partner having sex with other partners at the same time
• A sex partner with an STI
• Inconsistent condoms use when not in a mutually monogamous relationship
• A history of exchanging sex for money or drugs
• A history of incarceration
Chlamydia During Pregnancy
Those who are pregnant should be tested for Chlamydia and other STIs as part of their medical care. The results of an STI can be more serious, even life-threatening, for the mother and the baby if they become infected while pregnant. It is recommended those who are pregnant get screened during the first prenatal visit and again during the third trimester.
VHP members who are interested can ask their doctors about getting tested for all sexually transmitted infections.
Ambulance Billing Update
End to Surprise Ambulance Billing
California State Senate passed Assembly Bill 716 to protect patients from surprise bills for ground ambulance services.
• A VHP member who receives covered services from a noncontracted ground ambulance provider will not pay more than the amount that would have applied to a contracted provider.
• The law further prohibits the ambulance provider from attempting to collect from the insured member any amount greater than the in-network cost-sharing amount owed by the member.
Where to find cost-sharing amounts
• Explanation of Benefits: Once a claim has been paid by VHP, the Explanation of Benefits will clearly identify if the member has any financial responsibility. A digital version of the Explanation of Benefits can be accessed through the member portal, VHP Connect, at www.vhpconnect.org.
• Schedule of Benefits and Coverage Matrix (SOBM): This document provides a highlevel summary of benefits and cost-sharing amounts including Ambulance Services. Visit www.valleyhealthplan.org > Members > Forms and Resources:
• Employer Group SOBM (by group)
• Covered California SOBM (by metal tier)
• Individual & Family Plan SOBM (by metal tier)
VHP pays the ambulance provider directly
• Ambulance provider claims will be paid directly by VHP.
• Members are only responsible for paying cost-sharing amounts (if any).
• If an ambulance provider is attempting to bill you directly, please notify VHP Member Services at 1-888-421-8444 or memberservices@vhp.sccgov.org.
• Please note that members should not pay the claim directly to the ambulance provider nor seek reimbursement from VHP.
VHP Updates
Member Profile Updates: Sexual Orientation and Gender Identity
VHP’s mission is to ensure high-quality and affordable health care for all members. We will continue to provide equitable and inclusive health plan coverage and services to our LGBTQIA+ members, as well as advocate for all VHP members to be treated with respect and understanding.
During your next call to VHP, you may be asked to update your member profile with your preferred name, gender identity, sex assigned at birth, preferred pronouns, and sexual orientation. Collecting this information will help VHP understand the member population so we can improve services and provide the best care possible.
More
Important
Resources and Information
At VHP, we know that keeping up on how to get the most out of your health plan is important to you. So, we have made it easy. To find all your health information in one place, access our member portal, VHP Connect, at www. vhpconnect.org.
For information on the following subjects, visit: www.valleyhealthplan.org/ members/forms-and-resources or www.valleyhealthplan.org > Members
Tab > Benefits Handbooks. The Benefits Handbooks are also known as the Evidence of Coverage (EOC). This information is also available through alternative media upon request.
Advance Health Care Directive
Affirmative Statement About Financial Incentives
Autism Care Management Program
Change of Address
Choosing and Changing Your Primary Care
Practitioner (PCP)
Chronic Condition Management Program / Care Management
Combined Evidence of Coverage, including information such as:Benefits and services included and excluded from coverage
• Pharmacy management and general coverage
• Copayments and other cost sharing responsibilities
• Benefits and limitations to services outside the service area
• How to submit a claim for covered services
• How to obtain specialty care, behavioral healthcare services, and hospital services
• How to obtain care outside the service area
• How to obtain care after normal business hours
• Authorization and denial of services (Independent Medical Review eligibility and process)
Coordination of Benefits
Emergency and Urgent Care Services
Evaluation and coverage of new and existing technologies
Grievance and Appeals Process
Language Assistance
Lock-In Provision
Member Rights and Responsibilities
Non-Discrimination
Protected Health Information
Provider Directory / Search
Self-Refer Services (Direct Access)
Timely Access
Waste, Fraud, and Abuse
Teletypewriter and Telecommunications Device for the Deaf services are available for the hearing and speech impaired. Call the California Relay Service (CRS) by dialing 711 or the 800 CRS number of your modality.
The VHP Member Services Department has staff available Monday through Friday, 8 a.m. to 5 p.m. to assist with:
• utilization management issues
• authorizations
• claims
• benefits
• coverage
• general inquiries
Messages received after normal business hours are returned on the next business day, and messages received after midnight on Monday through Friday are responded to on the same day. If you need assistance, please contact VHP Member Services at 1-888-421-8444 or memberservices@ vhp.sccgov.org.
Language Assistance
VHP can help you in your preferred language at no cost. VHP provides over 150 languages to members including American Sign Language. We also offer materials in braille and large print options upon request.
All VHP members can receive free translation and interpretation services. To access language services, translated documents, or American Sign Language assistance, please call VHP Member Services at 1-888-421-8444 or email us at memberservices@vhp.sccgov.org.
