MassHealth Member Handbook - BMC HealthNet Plan
MassHealth Member Handbook - BMC HealthNet Plan
MassHealth Member Handbook - BMC HealthNet Plan
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public transportation, or there is<br />
a medical reason that you<br />
cannot use it.<br />
3. Your appointment must be for a<br />
Medically Necessary Service.<br />
4. You must see a <strong>MassHealth</strong><br />
Provider.<br />
For more information, contact our<br />
<strong>Member</strong> services department. You<br />
should contact the <strong>Plan</strong> well in<br />
advance of your appointment so<br />
we can process your request.<br />
Staying healthy<br />
The best health care happens<br />
before you get sick. It’s called<br />
preventive care. To help you stay<br />
healthy, we’ve put together a chart<br />
to show you all the tests and shots<br />
you and your children should<br />
have, depending on age. If you’d<br />
like a copy of the chart to be sent<br />
to you, please call the <strong>Member</strong><br />
services department. You can also<br />
find the chart on our Web site at<br />
bmchp.org.<br />
Preventive care for adults<br />
Routine preventive care is an<br />
important part of staying healthy.<br />
<strong>BMC</strong> <strong>HealthNet</strong> <strong>Plan</strong> encourages<br />
all <strong>Member</strong>s to visit their Primary<br />
Care Providers for preventive care.<br />
Examples of covered preventive<br />
care benefits for <strong>Member</strong>s ages 21<br />
and older include:<br />
• Physical exams every one to<br />
three years<br />
• Blood pressure monitoring<br />
at least every two years and<br />
whenever you have a visit with<br />
your PCP<br />
• Cholesterol screening every<br />
five years beginning at age 18<br />
or as recommended by your<br />
healthcare Provider<br />
• Pelvic exams and Pap smears<br />
(women) every one to three<br />
years (starting at age 21 or earlier<br />
if sexually active)<br />
• Breast cancer screening (mammogram)<br />
every year over age<br />
40 (or earlier if there is an immediate<br />
family history of breast<br />
cancer. Breast exams could<br />
then be as often as every six<br />
months.)<br />
• Colorectal cancer screening<br />
every 10 years starting at<br />
age 50 (or earlier if there is<br />
an immediate family history<br />
of colorectal cancer. In that<br />
case, exams could be more<br />
frequent.)<br />
• Flu shot annually<br />
• Eye exams once every 24<br />
months (or more often if there<br />
are certain medical conditions<br />
that exist.)<br />
• Dental. (Both adults and children<br />
are eligible for dental benefits.<br />
Some of these benefits<br />
are covered by <strong>BMC</strong> Health-<br />
Net <strong>Plan</strong>. Some are covered<br />
by <strong>MassHealth</strong>. Refer to your<br />
Covered Services list in this<br />
<strong>Member</strong> <strong>Handbook</strong> for details<br />
on dental coverage or call the<br />
<strong>Member</strong> Services department.)<br />
Prescription medication<br />
coverage<br />
Getting your prescriptions filled<br />
Your <strong>BMC</strong> <strong>HealthNet</strong> <strong>Plan</strong> healthcare<br />
Provider needs to write a<br />
prescription for both prescription<br />
medications and over-the-counter<br />
medications if you need them.<br />
<strong>BMC</strong> <strong>HealthNet</strong> <strong>Plan</strong> has more<br />
than 1,000 pharmacies in our<br />
Network across Massachusetts –<br />
including all the major chain stores<br />
– where you can pick up your<br />
medications.<br />
Our online Provider Directory lets<br />
you search for a pharmacy in your<br />
area where you can get your medicines.<br />
If you have problems finding<br />
a pharmacy, call our <strong>Member</strong><br />
services department.<br />
Paying at the pharmacy<br />
Unless you fall into one of the categories<br />
below, you will need to pay<br />
a Co-payment at the pharmacy<br />
for your prescription drugs. Please<br />
refer to your Covered Services list<br />
for information on Co-pays.<br />
Please note that <strong>BMC</strong> Health-<br />
Net <strong>Plan</strong> <strong>Member</strong>s pay the same<br />
Co-payments for prescription<br />
medications as <strong>Member</strong>s of other<br />
<strong>MassHealth</strong> Managed Care plans.<br />
Some <strong>Member</strong>s don’t have a<br />
pharmacy Co-payment<br />
You do not have a pharmacy<br />
Co-payment if:<br />
• You are under age 19.<br />
• You are enrolled in <strong>MassHealth</strong><br />
because you were in the care<br />
and custody of the Department<br />
Children and Families (DCF)<br />
when you turned 18, and your<br />
<strong>MassHealth</strong> coverage was<br />
continued.<br />
• You are pregnant. (You must<br />
tell the pharmacist you’re pregnant.)<br />
• It’s within 60 days following the<br />
month your pregnancy ended.<br />
• You are receiving family-planning<br />
supplies.<br />
• You are in hospice care.<br />
• You are a Native American or<br />
Alaska Native from a federally<br />
recognized tribe.<br />
• You are receiving Inpatient care<br />
in an acute hospital, nursing<br />
facility, chronic disease hospital,<br />
rehabilitation hospital, or<br />
intermediate-care facility for<br />
the developmentally delayed.<br />
• You have met the Co-payment<br />
cap for the calendar year<br />
(January through December)<br />
of $200. In January 2012, the<br />
cap for the calendar year will<br />
increase to $250. We’ll send<br />
you a letter to let you know<br />
13<br />
<strong>BMC</strong> <strong>HealthNet</strong> <strong>Plan</strong> <strong>Member</strong> Services Department<br />
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012<br />
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •<br />
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by<br />
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice<br />
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)<br />
<strong>MassHealth</strong> Customer Service<br />
8:00 a.m. – 5:00 p.m., Monday-Friday<br />
1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)