| SERVICES |
COVERAGE |
|
Diabetes Health Management Program
This free program is designed to help members who have diabetes. A major focus is on self-care and prevention.
|
You are eligible when:
- Priority Health pays for claims for a diabetes-related diagnosis,
test, or prescription drug.
- Your Primary Care Physician (PCP) refers you.
- You refer yourself by calling Customer Service
The Health Management Program provides:
- Educational materials
- Priority Health Registered Nurse phone calls if you have high
health risks
- Reminder postcards for preventive screenings such as A1c tests,
retinal exam, blood pressure, or cholesterol.
|
|
Diabetes education
Medications, tools, and diabetes diet plans change each year. If it has
been 5 years or more since you attended a class, you need to take a
refresher course.
|
Call your doctor (PCP) first. Tell the office you want to go
to a diabetes class. Choose a class held at a hospital that participates
with Priority Health.
- You may bring one friend or family member with you to classes for
free.
- A copayment may apply.
|
|
Doctor visits
A yearly physical exam is important even if you feel fine.
|
- This is a covered benefit. A copayment may apply.
- Tell your doctor (PCP) about any herbs, vitamins or
over-the-counter medications you are taking, or other prescriptions
from another doctor or dentist.
- When covered services (lab work, etc.) are performed in a hospital,
your hospital copayment applies.
|
Endocrinologist/diabetologist visit
This is for people who have trouble controlling their diabetes even
when they eat right, exercise and take their medications as prescribed.
Ask your doctor what is best for you. |
A doctor's (PCP) referral is
needed to see an endocrinologist. Without a referral, the visit will not
be paid for. The specialist must participate with Priority Health. A
copayment may apply. |
|
Ophthalmologist/optometrist
(dilated eye exam)
A dilated eye exam is different from a vision exam when you buy glasses
to read. A dilated eye exam checks for edema, bleeding and other eye
problems due to diabetes.
You do not need a doctor's (PCP) order to see an eye doctor for a
dilated eye exam.
|
We will pay for one dilated eye exam yearly if the doctor
participates with Priority Health. A copayment may apply.
- You do not need to use your vision insurance.
- Have a friend go with you to the exam. The drops placed in your
eyes, dilates your eyes, so you may not be able to read, or drive for a
few hours. Your eyes may be sensitive to light; bring sunglasses.
- Bring Priority Health's Diabetes Retinopathy form (PDF**) with you for the
eye doctor to fill out. (Forms on Web site) Ask to have results mailed
to your doctor (PCP).
|
|
Dietitian consult
A dietitian can help you develop a meal plan for your individual
needs.
|
- A doctor's (PCP) referral is needed to see a dietitian. It is a
covered benefit up to a maximum of 6 visits per contract year. A
copayment may apply.
- The dietitian must participate with Priority Health.
|
|
Podiatrist (foot care)
A podiatrist is an expert in the care of feet.
Ask your doctor (PCP) what is best for you.
|
Your benefit plan may include
coverage for prescriptions as an optional benefit at an In-Plan*
pharmacy. Please verify your coverage by checking your Member ID card. A
copayment may apply. |
Durable medical equipment (DME)
People with diabetes need special supplies. Supplies are available
through a DME Provider OR a Pharmacy Provider if you have pharmacy
coverage.
All Priority Health members have DME coverage, but check how much
your DME copayment is vs. your pharmacy coverage copayment. You may
decide to get your supplies from the provider with the lesser copayment.
If you do not have pharmacy coverage, you must use your DME
benefit.
|
- A prescription (for DME supplies) is needed from your doctor (PCP).
A DME copayment may apply.
- The provider must participate with Priority Health.
- Lancets are limited to a 30-day supply.
- Blood glucose test strips have a 31-day supply limit unless there
is a medical reason for more. If more are needed, you must have prior
approval by Priority Health.
- Pre-approval is not needed for standard glucose monitors.
- Pre-approval is needed for insulin pumps and for any DME item over
$1,000.
- DME may be rented, purchased or repaired.
|
|
Supplies by mail
You have a choice in providers:
- Walgreen's Mail Service
- Byram Healthcare
- Matria Healthcare
Insulin and other medications are only covered with a prescription drug rider.
|
Walgreen's Healthcare Plus:
- You must be an eligible member with a prescription drug plan.
- Your doctor (PCP) must write the prescription for a 90-day supply
or you will receive only a one-month supply. You may receive a 90-day
supply of test strips, lancets and syringes. Your pharmacy copayment
applies.
- To start the process, you must fill out a Registration Form from Customer Service.*
(PDF**)
Byram Healthcare:
- Call Byram at 800 681-1395 to set up an account. Be ready to give
your contract number and your doctor's (PCP) phone number and
address.
- Byram will then send a prescription form to your doctor (PCP) to
fill out to complete the process. Then, you only need to call Byram
once a month to place an order for your supplies. Your DME copayment
may apply.
Matria Healthcare:
- Call 800 928-8220 to set up an account. Be ready with your contract
number and your doctor's name and phone number. Matria will then
contact your doctor. Your DME copayment may apply.
|
Mental health/substance abuse care
People with diabetes are 2 to 3 times more likely
to become depressed. If you have feelings of depression for more than
two weeks or suffer from substance abuse, call our Behavioral Health
Department at 800 673-8043.
|
Our Behavioral Health
Department will determine what is clinically necessary and may authorize
services. It is not necessary to contact your doctor (PCP) to receive
mental health and substance abuse services. |