Referrals
What is a Referral?
When your PCP determines that you have a condition outside his/her scope of practice and you need to see a provider that specializes in treating that condition, the PCP will refer you to a specialist. To complete the referral process, the PCP must provide a completed online referral to the Varsity Health Charter Health Plan before you visit any other medical provider. Remember….the provider the PCP refers you to must be in the Charter Health Plan provider network!! Click here to see the Charter Health Plan Specialty Provider List. If you have services performed by a provider who is not part of the Charter Health Plan provider network, you will be financial responsible for any claims submitted by that provider.
How does the Referral process work?
After your PCP determines that you have a condition that requires you to see a specialist, the PCP will request a Referral on the Charter Health Plan Online Referral system. Once the PCP completes the Referral, either you or the PCP’s office will schedule an appointment with the specialist. It is highly recommended that you confirm with your PCP’s office that the referral was completed prior to scheduling an appointment with the specialist.
Do I need a Referral for gynecological care?
Yes, with the exception of your annual well woman visit.
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Prior Authorizations
What is a Prior Authorization?
A prior authorization is an approval from the Charter Health Plan for you to receive certain services. If your PCP or specialist has determined that your condition warrants the need for a particular test or surgical procedure (see list below), your case will be reviewed by a Charter Health Plan representative, who will then determine if the requested test or procedure meets the requirements for coverage. Your PCP normally obtains prior authorizations, as it is a review of your medical condition. However, you are responsible to ensure that you or your provider obtains prior authorization before a procedure is carried out. It is highly recommended that you take a copy of your authorization number with you the day of your test or procedure, as a precaution.
When do I need a prior authorization from the Charter Health Plan?
You will need a Prior Authorization for the following procedures:
- Hospitalizations.
- Outpatient Surgeries
- PET Scans
- More than three (3) visits to a single specialty within ninety (90) days
- More than six (6) visits to a single specialty within one (1) year.
- Out-of-network referrals (PCP requests will be considered by the Charter Plan Medical Director, under exceptional circumstances)
What happens if I do not obtain prior authorization from the Charter Health Plan for those services listed above?
If prior authorization is not obtained for the services listed above, you will have to pay the entire cost of the service. If, however, you receive any of the above services on an emergency basis, you, or your representative, have two (2) business days in which to obtain an authorization. Call 917-8500 in either case.
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Provider Network
What is the Provider Network?
The Charter Health Plan has established a “network” of physicians and facilities that work together to provide any necessary health services you may need. The ‘Network’ includes physicians, Sarasota Memorial Hospital and it’s outpatient facilities. The ‘Network’ gives you access to inpatient services, outpatient surgery, diagnostics services (such as x-rays and mammograms), and lab testing.
How do I know I am being referred to the right hospital, laboratory, x-ray department?
You may refer to the list included in your Charter Health Plan brochure or click here to access the network facility information.
How do I schedule testing at SMH facilities?
To schedule fasting lab tests, x-rays, or mammograms, call 917-7322.
What if I have a procedure or test done at a facility not in the network list?
In this case, you would have received Out-Of Network services. Except for medical emergencies, the Charter Health Plan does not cover the cost of care received from a non-network provider.
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Prescriptions
Where can I have my prescriptions filled?
You can have prescriptions filled at any Davidson’s or Target Pharmacy. Click here to see the locations and phones numbers for Charter Health Plan approved pharmacies.
Will my drug benefit cover prescriptions written by a physician who is not in the Charter Health Plan Network?
No. If you have a prescription filled that is written by a non-Charter physician, it will not be covered by the Plan and you will be financially responsible for the full amount.
What is the difference between a generic name drug and a brand name drug?
Generic drugs have the same active ingredients as brand name drugs, but are less expensive. Brand name drugs are manufactured by the company named on the application to the Food and Drug Administration (FDA) for new-drug approval. These companies make the initial investment for product research and development, resulting in higher costs for the brand name drug.
What is the difference in cost between a generic name drug and a brand name drug?
Your prescription medications are dispensed at the following rates:
Generic = $15 per 30 day supply
Brand = $40, plus the difference between generic and brand cost, when generic is available, per 30 day supply
You are encouraged to discuss your prescription drugs with your doctor to see if generics are acceptable substitutes for brand name drugs. This will help to keep your cost down for these medications.
What should I do if my prescription is rejected by the pharmacy?
First, confirm that the prescribing physician and the pharmacy are both in the Charter Health Plan Network. Once you have confirmed that the physician and the pharmacy are approved providers, contact the Charter Health Plan Pharmacy Case Manager at 917-8500 and select Option 3.
Will my prescription benefit cover all drugs?
No. Some drugs are excluded or may require prior authorization. Please refer to the Drug Coverage page in your Charter Health Plan brochure or click here to see the list of exclusions and those drugs requiring prior authorization.
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Charter Health Plan Member Identification (ID) Cards
What should I do if I have lost my ID card or it has been stolen?
Notify your employer that your card has been lost or stolen. Your employer will notify the insurance agent, who will have a new card sent to you. You will be required to pay a $5.00 replacement fee for the lost or stolen card.
What should I do if there is a change to my personal information on the card?
Notify your employer that your card requires a change in your personal information. Your employer will notify the insurance agent, who will have a new card sent to you. You will be required to pay a $5.00 replacement fee for any personal changes on your card.
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Primary Care Physicians (PCP)
What is a PCP?
A PCP is your Primary Care Provider, a physician who specialized in one of the following: Family Practice, Internal Medicine, Internal Medicine/Pediatrics, or Pediatrics. Your PCP is responsible for managing your care. When you completed your Charter Health Plan enrollment form, you were asked to choose a PCP from the Charter Health Plan Provider Directory (a list of all physicians in the Charter Health Plan Network). If you did not choose a PCP at the time of enrollment, one has been chosen for you. Please refer to your ID card if you are not sure of your PCP’s name.
Can a specialist be a PCP?
No.
When should I contact my PCP?
You should call your PCP’s office and schedule a wellness visit as soon as you receive your Charter Health Plan member ID card. When calling your PCP’s office, always identify yourself as a Charter Health Plan member. You should see your PCP within the first 90 days you are enrolled in the Plan. This is to help your PCP establish a baseline of your health for future reference.
What do I need to do to change my PCP?
The physician–patient relationship is an important one and members should feel comfortable with the PCP they have chosen. You may change your PCP once every calendar year by contacting 917-8500. Click here to see the Charter Health Plan PCP Provider List, or click here to change your PCP. Your new choice will go into effect the first day of the month following the change. You will receive a new identification card showing your new PCP’s name and phone number.
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Being An Active Partner
What can I do to be an Active Partner in my health care?
- Schedule your first PCP visit within 90 days of enrolling.
- Call you PCP before an Emergency Department visit, unless you have a life or limb-threatening injury or illness.
- Verify that all referrals are to in-Network providers before receiving services.
- Verify that all required prior authorizations have been obtained.
- Carry and present you Charter Health Plan ID card before receiving services.
- Use generic prescriptions whenever available.
- Always contact your PCP before receiving other health services.
- Refer to your Charter Health Plan brochure, view the Active Partner's Workshop or call 917-8500.
- Refer to your Healthwise Handbook or online health information for medical questions.
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