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About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (March 1, 2005)
* t r » • , • » j ' “Cha-may weeya ” Medicine Talk Siletz Community Health Clinic Health Program Update by Judy Muschamp Contract Health Service With the new year starting Jan. 1, 2005, the Contract Health Service (CHS) allocation has been restored. We are changing the way we manage our CHS dollars to ensure that funds remain available for high-priority care through out the entire year. Spending will be managed through quarterly allocations. The Gatekeeping Committee meets weekly to prioritize requests for specialty referred care. Pri ority I and II services are being consid ered for approval, with Priority III and above deferred for review at the end of each quarter. At the end of March, June, Septem ber, and December, the Gatekeeping Committee will consider whether fund ing is available for deferred services and all cases that have been deferred will be ranked in order of relative medical necessity. One CHS staff position was elimi nated during the budgeting process. Staff responsibilities are reassigned as follows: • • • • For prior authorization, if your last name begins with A - L, contact Rhonda Attridge For prior authorization, if your last name begins with M - Z, contact Danise Barker For questions about your Pequot pharmacy benefits or co-pay, con tact Jenifer Metcalf For questions about denials or ap peals, contact Shannon Case All visits must be pre-authorized. Emergency or urgent care must be re ported to CHS within 72 hours. On weekends or during evening hours, a clinic provider is on-call to advise you if you need emergency treatment. If you have any questions about CHS, how it operates, or what your re sponsibilities are, please call and ask for a copy of our CHS User’s Guide. Important CHS Phone Numbers 541-444-1236 1-800-628-5720 CHS fax: 541-444-9645 Health Care Outside the Service Area We anticipate new “out-of-area health” funding effective July 1, 2005. Between now and then, the Tribal Council will discuss new policies or rules for spending these funds in a fair and consistent manner. More information will be published as it becomes available, but tribal mem bers should be prepared to call Contract Health starting at 8 a.m. on July 1,2005, to request a share of health services funded by excess pledge revenue. We apologize that it’s difficult to get through, but we only have a limited number of staff to answer a limited number of phone lines. The good news is that effective Jan. 1, your Pequot pharmacy benefit was re newed for $500. Your card is good at most local pharmacies or you can ob tain mail order directly from Pequot. Mail order through Pequot is most cost effective for tribal members who live outside the service area. The Siletz Tribal Mail Order Pharmacy is not avail able outside the service area. The pro gram is not staffed or funded to operate as a nationwide distribution center. Siletz Tribal Mail-Order Pharmacy The Siletz Tribal Mail-Order Phar macy program is available to all CHS- eligible members. Here’s a few reminders to help the process go smoother: • • • • When calling in your prescription refill, be sure to specify whether you want the order mailed. If you don’t specify, it will be held for dis pensing at the window. Use the mailer envelope form for all new prescriptions. Fax orders are only accepted from your physician. Siletz Tribal Mail-Order Pharmacy will only dispense what your pri mary insurance allows. Some insur ance only allows a 30-day supply. When calling the pharmacy refill line, please remember to leave your name and phone number in case we have questions. • Your Pequot card was renewed with a $500 annual benefit limit. Once the $500 has been exhausted, it cannot be used again until next January. Please use this benefit wisely. The main purpose of retain ing the Pequot card is for prescrip tions you urgently need or for items that have been excluded from our formulary. How to Use Mail-Order Services For a refill on your prescription, call 1-800-648-0449 or 541-444-9624. Please leave a message. Send an order form and your new prescription to the address listed on the mail order service form/envelope. Please allow 7-10 working days for your order to be processed. If the pre scription is too soon to fill or not refill- able, you will be notified by phone. U.S. Postal Service will ship orders. Some medicines may require an adult signature upon receipt. Packaging is confidential. Business hours are 8:30 a.m. to 12:30 p.m. and 2 p.m. to 5 p.m. Mon day through Friday, except on Tuesday, 8:30 a.m. to 12:30 p.m. only. You have access to a registered pharmacist for consultation anytime during standard business hours. or myself, please do so as soon as possible. We cannot adjust your monthly reimbursement without correct information. Everyone who pays the minimum was automatically adjusted, but penal ized premiums cannot be calculated without the information that was provided to you by the Social Security Administration. On average, Medicare Part B pre miums increased 17 percent this year. If you need another copy of your state ment, you can call Social Security and request it. Also, anyone interested in enroll ing in the new Medicare Part D Pre scription program will be reimbursed that cost if you send me a copy of your premium notice. Send it to Judy Muschamp, Health Director, Siletz Clinic, P.O. Box 549, Siletz, OR 97380- 0549; 1-800-648-0449, ext. 1655, or 541-444-9655. A Formulary Limitation/Exclusion Categories Drugs used for cosmetic purposes Weight reduction products Fertility drugs Sexual performance enhancement drugs 5. Investigative drugs 6. Food supplements 7. Vitamins and over-the-counter products (not on the OTC formu lary list) 8. Compounded prescriptions are cov ered with limitations 9. Controlled substances for intrac table pain may be dispensed only in accordance with clinic policy. 1. 2. 3. 4. Medicare Reminder If you have not provided a copy of your new premiums to Amie Williams March 2005 \ Don’t Forget Diabetes Retreat The annual Diabetes Retreat will be held March 4-5 at the Shilo Inn in Newport. All tribal members who have diabetes should attend the two-day program and those attend ing may invite a support person. The keynote speaker will be Darryl Tonemah, an enrolled mem ber of the Kiowa Tribe and man of many talents. Dr. Tonemah has dedicated his professional career to empowering people, focusing especially on youth through leadership, wellness, self-esteem, parenting conferences, and alcohol and drug prevention. An accomplished entertainer, he has recorded five CDs that have been nominated for several Native American Music Awards and has appeared in two movies. Questions? Call Darcy Trego, Diabetes Program coordinator, at 541-444-9647 or 1-800-648-0449, ext. 1647. • Siletz News • 19
