We appreciate you choosing GlobalHealth and we look forward to serving you. Working proactively with each member, GlobalHealth engages a personalized management plan to address your specific needs and ensure the best possible health outcomes. GlobalHealth utilizes cutting edge, predictive data technology as a foundation to deliver improved healthcare as part of its commitment to making Health Insurance more affordable. This Member Handbook will familiarize you with your healthcare benefits. Please read the entire handbook; it provides important information about your benefit coverage. To look up the definition of a capitalized word in the handbook, please refer to the glossary. Please also review your Schedule of Benefits, Provider Directory, and Drug Formulary. These four documents form your Comprehensive Member Handbook. Call our Customer Care department, located right here in Oklahoma, if you have any questions. They are ready to help, and answer calls quickly. Visit www.globalhealth.com/state for more information on benefit coverage. We are happy you are part of the GlobalHealth family and wish you good health. Sincerely, R. Scott Vaughn, CPA President & CEO 2 This Certificate of Coverage is issued according to the terms of your group health Plan. Your group has contracted with GlobalHealth, Inc. to provide the benefits described. GlobalHealth, Inc., having been awarded a contract, certifies that all persons who have: Applied for coverage under this certificate; Paid for the coverage; Satisfied the conditions specified in Eligibility and Enrollment section; and Been approved by GlobalHealth, Inc. Are covered by this certificate. Beginning on your effective date, we agree to provide you the benefits described. Your effective date is stated on your Member ID card. No person or entity has authority to waive any provision or to make changes or amendments unless approved in writing by a GlobalHealth, Inc. officer, and the resulting waiver, change, or amendment is attached to this Certificate of Coverage. You are subject to all terms, conditions, limitations, and exclusions, and to all the rules and regulations of the Plan. By paying Premiums or having Premiums paid on your behalf, you accept the provisions of this Certificate of Coverage. This certificate replaces any previous certificates that you may have been issued. WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any Claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. PLEASE READ THIS DOCUMENT CAREFULLY. It is important for you to know your benefits. No oral statement shall add or take away any benefits, limitations, or exclusions, under this Plan. 3 Plan Issuer: 711 (TTY) GlobalHealth, Inc. Mon – Fri, 9 am – 5 pm PO Box 2393 Oklahoma City, OK 73101-2393 Pharmacy Benefits Manager: www.globalhealth.com/state Express Scripts Holding Company 1.866.274.1612 (toll-free) GlobalHealth Customer Care, Language 1.800.899.2114 (TTY) Assistance, and Disease Management: [email protected] Medication Prior Authorizations: 405.280.5600 [email protected] 1.877.280.5600 (toll-free) 918.878.7361 711 (TTY) Mon – Fri, 9 am – 5 pm Mail Claims to: Express Scripts 24/7 Nurse Help Line: Attn: Commercial Claims Information Line PO Box 14711 1.877.280.2993 (toll-free) Lexington, KY 40512-4711 GlobalHealth Compliance Officer: Mail Order Pharmacy: 405.280.5852 Express Scripts Customer Service Center 1.877.280.5852 (toll-free) 1.866.274.1612 (toll-free) [email protected] 1.800.899.2114 (TTY) 24 hours/7 days a week GlobalHealth Privacy Officer: www.express-scripts.com 405.280.5524 [email protected] *Specialty Pharmacy: Accredo Specialty Pharmacy Behavioral Health: 1.888.608.9010 [email protected] www.accredo.com 405.280.5600 1.877.280.5600 (toll-free) *Accredo Specialty Pharmacy is not the exclusive Specialty Drug Pharmacy. You have the option to use other pharmacies. 4 Welcome to GlobalHealth ........................................................................................................................ 2 Certificate of Coverage ............................................................................................................................. 3 Helpful Numbers ..................................................................................................................................... 4 Table of Contents ..................................................................................................................................... 5 Introduction .............................................................................................................................................. 9 Important Information ......................................................................................................................... 9 Member Materials .............................................................................................................................. 9 Accessibility and Translation Services ............................................................................................. 10 How to Get the Most Out of Your GlobalHealth Plan ...................................................................... 11 Member ID Cards ............................................................................................................................... 12 Steps to Improve Your Healthcare Quality and Safety ..................................................................... 13 Provider Network ................................................................................................................................... 14 Provider Directory ............................................................................................................................... 14 Primary Care Physician (“PCP”) ......................................................................................................... 16 Referrals ............................................................................................................................................... 18 Self-referral Services ............................................................................................................................ 18 Specialty Care ...................................................................................................................................... 20 Physicians Leaving the Network ......................................................................................................... 21 Urgent Care ......................................................................................................................................... 21 Emergency Care .................................................................................................................................. 22 Hospital Care ....................................................................................................................................... 23 Medical Records .................................................................................................................................. 23 Physician Credentials .......................................................................................................................... 24 Utilization Management Programs ....................................................................................................... 26 Medical and Behavioral Health Utilization Management ................................................................. 26 Pre-service Authorization ................................................................................................................ 26 Concurrent Review .......................................................................................................................... 28 Discharge Planning .......................................................................................................................... 28 Post-service Review .......................................................................................................................... 28 Prescription Drug Utilization Management ....................................................................................... 28 Exception Requests .......................................................................................................................... 29 Policy on Ensuring Appropriate Utilization ....................................................................................... 30 Technology Assessment Process ......................................................................................................... 30 Benefits ................................................................................................................................................... 32 Coverage Requirements ...................................................................................................................... 32 Behavioral Health Benefits ................................................................................................................. 33 5 Description of Covered Services ..................................................................................................... 33 Coordination of Care ....................................................................................................................... 36 Healthy Living Resources ..............................................................................................................