Please see the resources below for some helpful information and processes.
Dial 2-1-1 from anywhere in Connecticut and you will reach a trained call specialist who will assess your needs and provide referrals to the resources in your community. 2-1-1 is available 24 hours a day every day of the year. Multilingual assistance and TDD access is also available.
Dial 2-1-1 or search online at www.211ct.org.
Their website contains an eLibrary that has a wealth of health information for your use such as:
• Health Issues
• Locations of community health education seminars
• Disease specific resources
• Energy Assistance
• Legal and protective services
• Children and Families
• Public Safety
We encourage you to access this website and explore it to see what is available.
HealthyCT will cover all emergency services without prior approval in cases where you, acting reasonably, believe you have an emergency. You should get emergency care when you have severe pain or a serious illness or injury that will cause a lifetime disability or death if not treated at once. Examples of emergency conditions are:
- Chest pains or heart attack
- Choking or breathing problems
- A lot of bleeding
- Broken bones
If you can, call your Primary Care Physician (PCP). They can help you get the care you need. If you cannot call your PCP, call 911 or go to the nearest hospital emergency room for emergency care. If your doctor or a representative of HealthyCT tells you to go to the emergency room or another type of facility that can handle emergencies, the claim will automatically be paid. HealthyCT does not deny any emergency claims, however we will trend your use of the emergency room and if it is repetitive we will call you to determine:
- If you have a PCP and, if not, assist you in forming that relationship
- If you are experiencing any barriers to accessing non-emergent healthcare
- If you would benefit from case management or disease management services
- If you might benefit from a referral to a behavioral health team
If you are emergently admitted to the hospital by a HealthyCT contracted doctor to a contracted facility, then you do not need to do anything. However, if you are admitted by non-contracted doctor, you or your representative must notify HealthyCT within twenty-four (24) hours or the next business day. Once you are stabilized we may speak with your doctor to determine if you are stable enough to transfer to a contracted doctor and facility. This can only be done if your treating doctor agrees.
- Look in our provider directory for a contracted healthcare professional
- Ask your primary care doctor to recommend a professional
We have a network of licensed healthcare professionals to treat our members at all levels of acuity including social workers, psychologists, psychiatrists, and facilities from outpatient care, intensive outpatient care, partial hospitalization, residential facilities and acute care hospitals. The medical management processes for mental health substance abuse care are identical to those used for primary care and are conducted in the same a manner, whether pre-service, concurrent or urgent. Our case management and disease management programs are personalized to each individual. We offer:
- Improved access to mental healthcare
- Integrated utilization and case management
- Primary care and specialty care (including mental health and substance abuse) collaboration and coordination
From the Connecticut Insurance Department: Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
- A benefit denial
- The availability, delivery or quality of healthcare services
- Claims payment, handling or reimbursement for healthcare services
- Matters relating to the contractual relationship between a member and HealthyCT.
You may do so by calling Member Services at 855-208-1641.
For members who do not speak English, our customer service center has formed a relationship with “Language Line” to help us communicate through an interpreter. We also have bilingual staff that may be of assistance. You may use this service to speak with us by calling the Language Line at 866-874-3972 and our Client ID is 721845. Press “1” for Spanish and “2” all other languages. For members who are hearing and speech-impaired, we have a Text Telephone (TTY) device that lets people who are deaf, hard of hearing, or speech-impaired communicate over the phone by typing messages. A TTY is required at both ends of the conversation in order to communicate. Our Customer Service TTY Number is 855-643-5004.
The purpose of prior authorization is to prospectively evaluate proposed services to determine if they are medically necessary, covered by the member’s benefit plan, provided by a contracted practitioner or provider, where appropriate or possible, and provided in the most appropriate setting. In reviewing a prior authorization request for any type of admissions our Case Manager works with the appropriate doctors to determine whether:
- Your hospitalization is medically necessary and is a covered benefit;
- Your needs are safely addressed at the most appropriate level of care.
- A diversion to an alternate care facility or reduction in level of care is appropriate; and
- An admission to an inpatient rehabilitation program meets admission criteria
All requests are reviewed for medical appropriateness utilizing McKesson’s InterQual criteria, our Medical Policy or other evidence based standardized clinical sources if appropriate. Prior authorization nurses and behavioral health licensed staff have the authority to approve requests that meet the medical review criteria. Potential denials or questionable cases are referred to the Chief Medical Officer (CMO) or his/her designee for review. The CMO or Behavioral Health Medical Director are responsible for assuring that reviews of all potential denials are conducted by doctors of the same or similar specialty that have ordered the services. Our licensed healthcare professionals make all utilization management decisions based on appropriateness of care and services and do not receive any financial incentive to approve or deny payment for services. In you are receiving care from a non-contracted doctor and/or hospital it is your responsibility to make sure the prior authorization has been obtained by working with your doctor. Please see your certificate of coverage for any penalty that may be applied.
Our licensed professional staff review services that take place during an inpatient level of care or an ongoing outpatient course of treatment (for example, behavioral health partial hospital program [PHP], behavioral health intensive outpatient program [IOP] or home health care [HHC] services). This review continues throughout your hospital and/or facility stay. We monitor ongoing medical necessity, level of care and evaluate alternatives to inpatient care. We work closely with you, your doctor and facility to communicate coverage determinations in the appropriate manner and timeframe We use McKesson’s InterQual criteria to assess the appropriate level of care and length of stay. The determination of medical appropriateness includes consideration of your needs, as well as the requirements of the local delivery system. Clinical peers (same or similar specialty) are utilized in making medical determinations as needed. Concurrent reviews for acute and post-acute services are conducted by licensed healthcare professionals, who work closely with the Chief Medical Officer (CMO) or his/her designee as well as the Behavioral Health Medical Director. Non-clinical associates support concurrent review by data entry, receipt and documentation of notification. Concurrent review staff refers requests that do not meet guidelines or criteria to the (CMO) or his/her designee as well as the Behavioral Health Medical Director. If there is a potential denial, the (CMO) or his/her designee as well as the Behavioral Health Medical Director will refer the case to a clinical peer for final determination. During the concurrent review process, licensed professional staff identifies potential quality of issues and refer the issue to the quality review department for evaluation. Concurrent review may be conducted by phone, fax or, as applicable, on-site at the facility where care is delivered
Concurrent review RNs, LPNs or LMSWs help to facilitate your discharge to promote continuity and coordination of care in conjunction with your doctor, the hospital discharge planner, and you or your authorized representative to assure a timely and safe discharge. Discharge planning is part of the Utilization/Care Management Program and includes, but is not limited to:
- Assessment of your continuity of care needs including benefit eligibility;
- Assessment of your support system to determine necessary services;
- Development of a plan of care based on short-term medical/psychosocial needs;
- Coordination and implementation of services requested in the plan of care.
A retrospective review is any review for care or services that have already been provided. We will review post-service requests for authorization of inpatient admissions or outpatient services. The review includes making coverage determinations for the appropriate level of services, applying the same approved medical criteria used for the pre-service. This type of review is applied to cases such as urgent or emergent services and out-of-network services that require prior authorization which was not obtained.
Disease Management Programs Help You Better Manage Your Condition
Living with asthma and/or diabetes can be hard, but we have a program that can help! Our Disease Management Program helps educate our members with asthma and/or diabetes so they can better manage their conditions. We’ll identify members who could benefit from this program and mail them information on a quarterly basis. For those members with more critical needs, we’ll provide access to one of our Disease Management Nurse Case Managers.
If you’re interested in learning more about these programs, please call Member Services at the number on your ID card and speak with one of our Disease Management healthcare professionals. Your doctor can also help you enroll in the program. Please be assured that our Disease Management Programs are voluntary and offered at NO COST to you. You can also opt out of the program at any time.
Complex Case Management
Living with health problems and managing them can be hard. We have programs that can help. Our Complex Case Management program is for members with difficult health problems who need extra help with their healthcare needs. We can help you:
- Coordinate health services – along with your doctor and other health professionals
- Transition smoothly from another carrier to HealthyCT
- Understand your medical conditions and medications
- Manage your health needs – with your physician
- Identify warning signs that indicate your condition is getting worse
- Schedule doctor appointments and help you prepare for your visit
- Locate community resources that you might find helpful
- Support healthy lifestyle changes you choose to pursue
There are many ways you can be referred to a program. One way to enroll is through your provider. You also can self-refer to the program by calling Customer Service at 855-208-1641. They will refer your case to one of our Case Management healthcare professionals. They will assess your needs to determine if you qualify for the program. This program is voluntary and is offered at NO COST to you. You can choose to be removed from the program at any time.
- A right to receive information about HCT, its services, its practitioners and providers, and its member rights and responsibilities.
- A right to be treated with respect and recognition of their dignity and their right to privacy.
- A right to participate with practitioners in making decisions about their healthcare.
- A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
- A right to voice complaints or appeals about HCT or the care it provides.
- A right to make recommendations regarding HCT’s member rights and responsibilities policy.
- A responsibility to supply information (to the extent possible) that HCT and its practitioners and providers need in order to provide care.
- A responsibility to follow plans and instructions for care that they have agreed to with their practitioners.
- A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
HealthyCT looks at new technology and the new application of existing technology for benefits you have now. We review all the studies done to see if services should be added to your benefit package. We review these types of services listed below at least once a year:
- Medical and Surgical services
- Behavioral Health services
New technology and the new application of existing technology are extensively reviewed. We use doctors of the same or similar specialty that would be ordering the service to review the technology and our research results. We use multiple sources to review these services for safety and effectiveness. Some of the sources we use are:
- Peer-reviewed scientific studies published in or accepted for publication
- Peer-reviewed literature, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s National Library of Medicine
- Medical journals recognized by the Secretary of Health and Human Service
- Peer-reviewed abstracts accepted for presentation at major medical association meetings
For us to approve the new services as a benefit all three (3) of these conditions must exist:
- If a technology improves health outcomes when current therapies have not been effective in significantly improving your condition or would not be medically appropriate. The technology would improve: length of life, ability to function and/or quality of life. In addition, there should be evidence or that it affects health outcomes
- The technology has final approval from appropriate government regulatory bodies such as the Food and Drug Administration (FDA) for medicines
- The evidence consists of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the studies and the consistency of the results is considered in evaluating the evidence.
How is Clinical Criteria Developed?
Criteria are developed using nationally recognized references and guidelines such as:
- Clinical Pharmacology
- Thomson Micromedex DrugDex
- American Hospital Formulary Service-Drug Information (AHFS-DI)
- National Cancer Comprehensive Network (NCCN) Drugs and Biologics Compendia
- Facts and Comparison
- National Guidelines Clearinghouse
- Food and Drug Administration
- Center for Drug Evaluation and Research (CDER)
- Pharmacist’s Letter
- Center for Medicare and Medicaid Services
- Professional Organizations (e.g., American Diabetes Association)
A review of clinical criteria is completed annually and available on our website for members and doctors here. If you are unable to access a computer, you can call OptumRx’s Customer Service Department at 855-577-6549. A notice will be sent to your doctor that the information is available on the website.
How are Drugs Selected for the Formulary: Pharmacy and Therapeutics Committee (P&T)?
OptumRx’s Pharmacy and Therapeutics Committee provide clinical criteria that are based on clinical information that includes:
- Assessing peer-reviewed medical literature, including: randomized clinical trials, drug comparison studies, pharmacoeconomic studies, and outcome research data.
- Published practice guidelines, developed by an acceptable evidence-based process.
- Comparison of the efficacy as well as the type and frequency of the side effects and potential drug interactions among alternative drug products.
- Assessing the likely impact of drug product on patient compliance when compared to alternative products.
- Basing formulary system decisions on a thorough evaluation of the benefits, risks and potential outcomes for consumers.
- Prior to Pharmacy and Therapeutics Committee review, new drugs are added to the formulary at a default status of non-preferred brand so the consumers have access to drugs when they become available.
How Are Pharmacists and Doctors Involved in the Development of Pharmacy Processes?
The pharmacy programs are evaluated at least annually and updated if necessary and appropriate. Actively practicing physicians and pharmacists, with current knowledge relevant to the criteria are part of this process. Additionally, actively practicing doctors licensed in the State of Connecticut review the criteria. These doctors are of the same or similar specialty of the doctor that would be prescribing the drug.
How to Obtain Information about Specific Drugs?
OptumRx, on HealthyCT’s behalf, hosts a web tool that will let you know if a drug requires prior authorization, has quantity limits or is on the formulary. You can access this information here. If you are unable to access a computer, you can call OptumRx’s Customer Service Department at 855-577-6549. Example: (QL=Quantity Limits, PA=Requires Prior Authorization)
What is prior authorization?
Prior authorization means we need to review a medication before your plan will cover it. We want to know it’s the right medication for the right situation. If you don’t get prior authorization, a medication may cost you more, or it may not be covered at all. Drugs that are typically prior authorized are:
- Drugs that have dangerous side effects or can be harmful when combined with other drugs
- Drugs that should be used only for certain health conditions
- Drugs that are often misused or abused
- Drugs that are prescribed when less expensive drugs might work better
If your drug needs authorization either you or your pharmacist will need to let your doctor know. They might switch your therapy to another drug that doesn’t require approval from the health plan. Or your doctor will contact OptumRx’s Customer Service Department at 855-577-6549 to start the approval process and tell us the information we need.
What is a Formulary?
A formulary is a specific list of drugs that are covered. A tier refers to grouping of drugs on the formulary that are typically associated with a particular co-payment/co-insurance. The lowest tier includes generic or other drugs with the lowest co-payment, the middle or second tier may include preferred brands and the highest or third tier may include non-preferred brands. HealthyCT has two different types of formularies: closed and open. A closed formulary means that drugs not on the formulary list are typically not covered. However, if there is a medical reason that a member would need to use a non-formulary drug, for example, they are allergic to the formulary drug, then the practitioner can call OptumRx for a prior authorization (PA). An open formulary has a relatively unrestricted list of drug choices. In this case the member may see a higher co-pay/coinsurance for non-preferred drugs. How to identify which formulary you have:
- Closed Formulary (Traditional): Individual and Small Groups: If your Group ID has the letter “I” or “S”. Ex: HCTFXI00000 or HCTFXS00000
- Open Formulary (National): Large Groups: If your Group ID has the letter “L” in it. Ex: HCTFXL00000
To determine which drugs are on PA, use the OptumRx drug look-up tool.
What Is Generic Substitution, Therapeutic Interchange and Step-Therapy?
Generic Substitution is the dispensing of a chemically equivalent but less expensive drug in place of a brand-name product that has an expired patent. Step therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapy, only if necessary. Therapeutic Interchange is the practice of replacing a patient’s prescription drugs with chemically different drugs that are expected to have the same clinical effect. When making decisions regarding the substitution programs above, OptumRx assesses:
- Efficacy as well as the type and frequency of the side effects and potential drug interactions among alternative drug products.
- The likely impact of drug product on patient compliance when compared to alternative products.
- The benefits, risks and potential outcomes for consumers.
You can find the drugs in these categories, on the OptumRx website here. If you are unable to access a computer, you can call OptumRx’s Customer Service Department at 855-577-6549.
How do I request an exception?
There are several types of exceptions to our coverage rules that you can ask us to make:
- Step therapy;
- Quantity limits; or
- Non-formulary drugs
Generally, we will only approve your request for an exception to the formulary if the alternative drugs included on our formulary, or additional utilization restrictions, would not be as effective in treating your condition and/or would cause you to have adverse medical effects. When you are requesting a formulary or utilization restriction exception, you should have your doctor submit a statement supporting your request. Generally, we must make our decision within 72 hours of getting your doctor’s supporting statement. If your request is not granted, you do have the right to appeal (please see your certificate of coverage for the process).
Drug Recall Process
Drug product recalls and safety-related market withdrawals are announced by manufacturers, by requests from the FDA, or by FDA orders under statutory authority. If you are using a drug that is recalled, you will receive a letter explaining the reason(s) for product recall or safety-related market withdrawal and it will advise you on contacting your doctor for further instructions. Your doctor will also receive a notice of the recall.
Please click here to view HCT medical policies.