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Envision Rx Plus medicare Retirees
An Introduction to Envision Rx Plus medicare Retirees Options – 844-293-4760
Envision Pharmaceutical Services, created in 2001, with a commitment to providing transparency and disclosure to the Pharmacy Benefit Management (PBM) marketplace, provides full service, integrated PBM services, including network-pharmacy claims processing, home delivery (mail-order), benefit-design consultation, drug-utilization review, formulary management, disease management, and drug data analysis services. Envision also provides a full range of injectable and infusion biopharmaceutical products directly to patients or their physicians, and provides extensive cost-management and patient-care services
Introduction to INDECS Corporation
1(888) 4‐INDECS (446‐3327)
INDECS CORPORATION is the Health Plan’s Third Party Health Administrator (TPA). As a self‐funded
municipal cooperative plan, the Orange Ulster School Districts Health Plan (OUSDHP) employs INDECS to
administer the Plan in accordance with the Plan’s provisions.
INDECS’ Customer Service answers Plan Members’ questions regarding claims status, benefit provisions,
the Plan’s Prescription Drug Program, eligibility, student and COBRA status, issues Plan ID cards, and
performs other administrative activities.
To review your claims history, claim payment status, eligibility and other enrollment information, members can access the INDECS Connection 24 hours a day, 7 days a week by clicking on the above link to the INDECS website. (Requires personal registration for HIPAA privacy and security.) You may also contact INDECS directly at 1(888) 446‐3327 to speak with a Customer Services Representative.
INDECS also coordinates overall Plan benefit management, bringing centralized administration to the Plan Membership. Working with the Health Plan’s Trustees, and the participating School Districts’ Directors, INDECS acts as a facilitator to multiple associated Plan vendors such as: National Blue Cross/Blue Shield, the Plan’s designated Participating Provider Organization “PPO”; EnvisionRx Options, the Plan’s general pharmacy and specialty pharmacy benefits manager; HealthCare Strategies (HCS), the Plan’s utilization review company; Quantum Network, the Plan’s behavioral PPO network and management services; Optum Health, the Plan’s physical therapy and chiropractic PPO network
TO BE SURE YOU RECEIVE THE HIGHEST LEVEL OF BENEFITS WITH THE LOWEST “OUT‐OF‐POCKET”
COSTS, ALWAYS BE SURE TO USE A PPO IN‐NETWORK PROVIDER.
While most hospital, medical and surgical claims are submitted directly by providers (to the Plan’s
primary medical plan PPO network ‐ National BC/BS), the claims are processed by INDECS and paid by
your Plan. The OUSDHP processed claims are then available on your personal web page on the INDECS
Connection website at www.indecscorp.com. Click on “INDECS Login” to register your private account,
The Plan Document;
Plan Benefit Summary;
Sign up for paperless Explanation of Benefits (EOBs);
Review recent OUSDHP Health Beat newsletters, and
Other administrative forms and communications.
OptumHealth Care Solutions, Inc.
(*These benefits are administered by OptumHealth Care Solutions, inc. under the brand “Optum” for reference.)
Introduction to Optum – (1-888-471-0117)
About Our Program
As part of Optum, the managed physical medicine program offers chiropractic, physical therapy and occupational therapy services to Orange Ulster School Districts Health Plan members.
Optum is a physical medicine company that has been providing physical medicine programs since the 1980s. Built on the same successful model as our chiropractic care services, physical therapy services were added in 1995. Our physical therapy networks include specialists in all seven board certifications of the American Board of Physical Therapy Specialists.
Access to Quality Network
Our extensive network combined with our on-site clinical staff, unique educational programs, and best practice initiatives, have made us one of the most respected authorities on physical medicine in the health care industry.
Using our knowledge and experience, we have designed innovative processes and technological capabilities that are targeted at improving the health care experience for the patient and the health care professional.
We are committed to helping ensure that you have access to safe, high quality, affordable chiropractic and physical therapy treatment that is specific to your needs and is aligned with current science.
One of our most important jobs is to help you navigate the complex requirements of today’s health care environment efficiently so that you can be confident you are getting the best care possible.
You benefit from our Clinical Support Program in several ways:
• Access to providers who have successfully passed our rigorous credentialing process.
• Receive treatment that is consistent with current best evidence resulting in improved quality and affordability of chiropractic and physical therapy care.
• Availability of decision-support resources to help you decide which chiropractor or physical therapist to see for your condition
• Minimize the complexity of the various tranactions associated with seeking chiropractic or physical therapy treatment
We work with our network in a variety of ways to provide chiropractors and physical therapists with information that helps to ensure patients improve as quickly as possible. We are highly respectful of your relationship with your chosen chiropractor and/or physical therapist and attempt to leave the decision-making regarding your specific treatment up to you and your practitioner.
Quantum Health Solutions, Inc.
Quantum Health Solutions, Inc., is the comprehensive behavioral health care management program for benefit-eligible employees of OUSDHP. Quantum offers a full range of specialty behavioral health services provided by a culturally diverse network of licensed community behavioral health programs, clinics and private psychiatrists, psychologists, and therapists/counselors.
Some people seeking behavioral health services require only basic counseling services, but for those who are in need of more extensive treatment, OUSDHP medical benefit offers an range of behavioral health services. Quantum offers centralized diagnostic and referral functions that include identification of the most clinically appropriate and cost-effective level of intervention.
Our team of professionals monitors all phases of and during the treatment process, starting with the initial request for treatment. Case managers assess the necessity and appropriateness of treatment, develop a plan for monitoring care and approve provider treatment plans with internal protocols and criteria for clinical care.
Our on-going review process monitors treatment for frequency, duration and efficiency. Alternative modalities of care are developed and recommended as circumstances dictate. We work with you to coordinate treatment planning, which provides for early identification of effective alternatives, allowing better management of care transition from acute to palliative care. During aftercare monitoring, the case manager assists the patient in making a complete transition from treatment to normal living activities. This stage guards against relapse and inappropriate re-entry into treatment.
Pre-certification process starts by calling 888-214-4001. Access to in-network coverage for mental health and substance abuse treatment, either inpatient or outpatient is through Quantum. You can contact one of our network providers and schedule an appointment, and contact Quantum to take the next step. The Quantum Case Manager, after speaking with you about your individual and special concerns, will prepare the authorization for the most appropriate service(s) to meet your specific needs. You have access to the following services:
Outpatient benefits will allow members to access care with Quantum NET and Blue Cross Blue Shield psychiatrists, psychologists and social workers for in-network coverage. *Non pre-certified and out-of-network provider claims are reimbursed at the out-of-network rate.*
Inpatient benefits will allow members to access care to Quantum NET and Blue Cross Blue Shield facilities for treatment when medically appropriate. It is important to remember that you must call Quantum for admission pre-certification. Emergency and crisis treatment require you to contact Quantum the following business day for retroactive pre-certification. *Non pre-certified and out-of-network provider claims are reimbursed at the out-of-network rate.*
Claim coordination with the plans claims administrator occurs daily with the Quantum Case Management team. If you have any questions regarding the claims process, call the plan claim administrator and if additional assistance is warranted call the Quantum Case Manager at 888-214-4001 for further assistance.
HealthCare Strategies, Inc.
HealthCare Strategies (HCS) is a managed care company that the OU Health Plan has contracted with to assist Plan members in making informed decisions about their health care. HCS is dedicated to helping the OU Health Plan members improve their health and wellness through a number of programs.
HCS provides member access to Care Counselors, who are Registered Nurses, 24 hours a day, 365 days a year. They provide callers with toll-free, confidential health care advice and information. The programs are based on the premise that informed patients make better and more cost effective health care decisions.
HCS provides several programs to assist members.
The Medical Information Helpline (1-800-582-1535) assists members when there are questions or concerns about: medical care; side-effects’ how to locate a qualified health care provider; hospitalization is required; an outpatient procedure; a drug or alcoholic concern; or any time information or answers on medical services or procedures are needed.
The HealthReach Program (1-800-582-1535) gives members personal assistance to help understand and manage specific medical conditions or minimize potential side effects of prescription drugs. The HealthReach Program does not make decisions for members but provides information and clarification to assist in making appropriate decisions.
The MaterniCare Program (1-800-582-1535) is based on proactive communication with expectant mothers. Expectant mothers should call to enroll within 30 days of the diagnosis of pregnancy in order to receive the full benefit of the MaterniCare Program. The participating mother is provided a personal RN-MaterniCare Counselor who can be reached through a 24 hour information line. Customized educational information is provided to the mother throughout her pregnancy.
The Large Case Management Program (1-800-582-1535) is there for members who may have a catastrophic injury or chronic care needs. The Case Counselor becomes the primary coordinator, patient advocate and counselor for the member to ensure that the member receives the best quality of care available.
Remember that HealthCare Strategies Services Programs are provided without cost to members enrolled in the OU Health Plan; provide confidential & specialized information to help individuals to achieve maximum health; cannot make decisions for you; can be accessed 24 hours a day, 7 days a week.
CVS Caremark provides full PBM services including network-pharmacy claims processing, home delivery (mail order), drug utilization review, formulary management, disease management, and drug data analysis services. CVS Caremark also provides a full range of injectable and infusion biopharmaceutical products directly to patients or their physicians, and provides extensive cost-management and patient-care services.