Benefit Descriptions 24 hours or one (1) business day. If you are completely out of your prescription, call your Plan Pharmacy, Plan Provider, or VHP Member Services at 1.888.421.8444 (toll-free). If the request for Authorization is denied, VHP will notify you and your Physician in writing, within two (2) business days, of the reason for the Denial. You will be referred back to your Plan Physician for alternative treatment and/or to contact VHP or PBM Customer Care for further assistance. The notice will also inform you of your right to dispute the Denial. If you have questions, speak with your Plan Pharmacist, Plan Provider, a PBM Customer Representative (1.866.333.2757 toll-free), or a VHP Member Services Representative. In the event Member needs to file a Grievance with the Plan, the Member must contact VHP Member Services. If VHP denies the Member Grievance, VHP will notify the Member in writing of the reason for denial. The notice shall also inform the Member of their right to dispute the decision. Emergency prescription drugs are filled according to the provider’s prescription. Should you need to obtain a prescription associated with out-of-area Emergency Services or Urgently Needed Services, take your prescription to a Plan Pharmacy. If a Plan Pharmacy is not available, VHP will cover the prescription filled at an Out of Network Pharmacy. Refer to the “Payment and Reimbursement Responsibility” section under “Reimbursement Provisions (Claims)” for reimbursement procedures.
At the Time of Your Enrollment If you are taking prescription drugs at the time you enroll, please make an appointment with your Primary Care Physician for evaluation of your current medication and your continuing care. If your Plan Provider determines that you need a prescription, you will receive either a prescription for your current medication or a new prescription for a drug(s) from the Formulary that is equally effective.
Inpatient Pharmacy Services For inpatient care, Covered Services include drugs, supplies, and supplements. Inpatient hospital and other facility drugs and supplements are provided in accordance with your Plan Physician’s prescription and Plan Formulary. Applicable Copayments and other Member charges apply. Refer to the “Benefits Description Table” for additional Covered Services information.
Durable Medical Equipment - Medical Supplies & Equipment Medical Supplies and Equipment are covered under your Benefit Plan through Durable Medical Equipment (DME) Plan Providers. Coverage is limited to the basic Medically Necessary item of equipment that adequately meets your medical needs. Deductibles, Coinsurance, and Copayments may apply. Refer to the Summary of Benefits and Coverage at the front of this booklet. Note: The dollar amount of Deductibles, Coinsurance, and Copayments can be $0 (no charge). Your Plan Physician will prescribe when Medically Necessary. If Prior Authorization is required (e.g. DME and prosthetic devices) your PCP or Plan Physician will arrange it. Covered Services include: • Durable Medical Equipment; • Corrective appliances; • Prosthetic Devices; • Prescription Orthotic Devices; and • Oxygen and oxygen equipment.
57 V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M
