FAQs related to emergency care.
If you believe you or someone you know is having a life-threatening medical emergency, you should dial 9-1-1 to get medical care immediately. You do not have to contact your primary care provider (PCP) or get permission in an emergency.
If you need to talk with your doctor, or get medical care when your doctor’s office is closed and it is not a medical emergency, call your doctor’s office. Most doctors have an after-hours answering service. Be sure you leave a message for your doctor. If your doctor is not available, there will always be a health professional on call to help you.
Health Choice Utah covers emergency care that you get from non-plan providers when you are outside the plan’s service area but still in the United States. If you need urgent care while you are outside the plan’s service area, please call your doctor. Your doctor will give you advice about what you should do.
FAQs related to medical bills and claims.
In most cases, no. As long as you were enrolled with Health Choice Utah when you saw the provider, you do not have to pay for covered services.
If you get a bill from your provider, please send the bill to Health Choice for review. We will be happy to tell your provider that, as a Health Choice Utah member, you do not have to pay for covered services. If you paid for covered services while enrolled with Health Choice, your provider should refund your money, minus any copay amount, to you.
The Explanation of Benefits (EOB) may look like a bill, but it is not. The EOB explains to the member the services that the health plan has covered, how much was paid and if there is any balance that the member may still owe to the provider. If the claim was denied, the EOB will also provide an explanation. If you have any questions or concerns about the EOB, call the Member Services Department at 1-877-358-8797.
FAQs related to complaints.
If you have a question or problem, please call 1-877-358-8797 and ask to talk to a Member Services Representative. We are here to help you. If you have a specific complaint about your medical care, the Member Representative will help you.
If you are unhappy with the answer you receive, first talk to a manager. If you are still unhappy, tell the Member Services Representative you want to file a written or oral grievance. The grievance must be filed not later than 60 days after the date of the action, decision, or incident.
Please call Member Services and speak to a representative about making a complaint.
FAQs related to your prescription drug benefit.
If your pharmacy is not in our network, you can transfer your prescriptions to a new pharmacy.
Follow these two steps:
- Locate a pharmacy in our network:
- Visit our website and use the Find a Pharmacy search or
- Contact Pharmacy Customer Services, and we will find a pharmacy for you.
- Tell your new pharmacy that you want to have your prescriptions transferred. Give them the contact information for your current pharmacy. The new pharmacy will contact your current pharmacy and make the transfer.
You should always go to a pharmacy in the Health Choice Network. A pharmacy that is not in our network cannot help you fill your prescription or help with your drug benefits.
If you use a pharmacy that is not in our network, you will have to pay the full cost of the drugs. Your drugs may not be eligible for reimbursement; this means you will not get paid back if you pay out-of-pocket for your medication.
If your pharmacy is not in the Health Choice network, please give us their name, address and phone number. We will contact them to see if they will join our network.
The guidelines regarding co-pays can be found in your Member handbook.
Health Choice Utah’s preferred specialty pharmacy is assigned during the Prior Authorization process.
How does a specialty pharmacy work?
- Your specialty prescription must be filled at the specialty pharmacy designated in your Prior Authorization letter.
Need additional information about specialty medications or specialty pharmacies? Call Pharmacy Customer Services at 855-864-1404 (TTY 711). Pharmacy Customer Service is available 24 hours a day, 7 days a week, 365 days a year. We are always here to help!
Please refer to the Health Choice list of covered drugs, also called a formulary. You can find the list on our website. If you would like a printed copy, please call Pharmacy Customer Service.
Your pharmacy will tell you. You will still be able to get your drugs in the same visit. Your pharmacy will get approvals from Health Choice and your Behavioral Health Agency.
A formulary is a list of drugs that are safe and economical. An independent committee of doctors and pharmacists develops the Health Choice formulary. The independent committee reviews and updates the formulary regularly to include new drugs and treatments.
The formulary contains a wide range of drugs. The Food and Drug Administration (FDA) have approved all drugs on the formulary.
Health Choice covers all drugs listed in the formulary. Health Choice will not cover drugs not listed in the formulary.
A brand name drug is protected by a patent. The patent protects the drug so that only one drug company can make it.
When the patent for a brand name drug ends, other drug companies can make a version of the drug. This is called a generic drug. A generic drug is a chemical copy of the brand name drug. The color or shape may be different, but the active ingredients are the same.
Some drugs require prior authorization. Specific criteria must be met before Health Choice can cover these drugs.
The pharmacist will find out if a drug requires prior authorization when the pharmacist submits your prescription for approval. Your pharmacist may submit the request for prior authorization at that time.
In some situations, your pharmacist may not have all the information to get the drug approved. When that happens, your doctor will contact Health Choice to request prior authorization.