True Health New Mexico | true to your health | Summer 2019

Bill Age 58 Problem: Crushing pain in chest for over 2 hours Wait to see ER doctor: 10 minutes Alternative: None—this is a true emergency Linda Age 22 Problem: Sore throat for 1 day Wait to see ER doctor: 4 hours Alternatives: Call to nurse advice line/possible virtual clinic visit; urgent care $500: Member cost-share for ER visit $0: Member cost-share for nurse advice line; possible copay if prescription given via virtual clinic visit $50: Member cost-share for urgent care visit Jill Age 32 Problem: Rolled ankle while run- ning today; mild to moderate pain Wait to see ER doctor: 3 hours Alternatives: Over-the-counter pain medications and rest/ice/ compression; primary care physician $350: Member cost-share for ER visit Less than $10: Member cost- share for over-the-counter acetaminophen or ibuprofen and compression wrap $10: Member cost-share for primary care visit Jose Age 63 Problem: Pain- ful callus on foot Wait to see ER doctor: 6 hours Alternative: primary care physician $750: Member cost-share for ER visit $35: Member cost-share for primary care visit Jim Age 28 Problem: Dry cough for 2 days Wait to see ER doctor: 4 hours Alternative: Over-the-counter cough syrup 50%: Member cost- share for ER visit after deductible is met $2 to $12: Member cost-share for over- the-counter cough syrup The cost of care GET THE CARE YOU NEED— AT THE BEST PRICE W e would like to remind you about our website, truehealthnewmexico.com . There are many helpful items to read on our website. You can view and/or download information about the following topics: • Information about our pharmacy procedures and coverage of drugs, includ- ing copayments; True Health NewMexico’s drug list along with restrictions and preferences; how to use our pharmacy procedures; an explanation of limits and quotas; how to receive coverage for non-formulary drugs and an explanation of how practitioners can provide information to support an exception; and True Health New Mexico’s processes for generic substitution, therapeutic interchange and step-therapy. • Information about how you may obtain information about network practitioners and the professional qualifications of practitioners, includ- ing specialty, medical school attended, residency completed and board certification status. • Information about benefits and services included in, and excluded from, coverage. • Information about copayments and other charges for which you are responsible. • Information about restrictions on benefits that apply to services ob- tained outside True Health New Mexico’s system or service area. • How you may obtain primary care services, including how to choose and access a primary care practitioner. • How you may obtain specialty care and behavioral health services and hospital services. • How you may obtain care after normal office hours. • How you may obtain emergency care, including True Health NewMexico’s policy on when to directly access emergency care or use 911 services. • How you may obtain care and coverage when you are out of True Health New Mexico’s service area. • How you may appeal a decision that adversely affects coverage, benefits or your relationship with True Health New Mexico. • A description of the availability of an independent external appeals process for utilization management decisions made by True Health New Mexico. • True Health New Mexico’s member rights and responsibilities statement. • How you may voice a complaint. • How you may submit a claim for covered services, if applicable. • How to contact staff if you have questions about how we manage care and services (UM) and the toll-free number to call to contact staff. • Information about True Health New Mexico’s Case Management Pro- gram and how you or your caregiver may self-refer to the Program. • Information about True Health New Mexico’s Disease Management Programs and how you or your caregiver may self-refer to the Programs. • Information about True Health NewMexico’s Quality Improvement Pro- gram including goals, processes and outcomes as related to care and service. • True Health New Mexico’s policy prohibiting financial incentives for utilization management decision-makers. • How True Health New Mexico evaluates new technology for inclusion as a covered benefit. • How to obtain language assistance to talk with us about how we man- age care and services or to obtain information about benefits, access to services, and other issues. • The availability of TDD/TTY services. There is other information about True Health New Mexico and our services on the website that is useful to know. Our physician and hospital directories allow you to select a physician or hospital that best meets your needs. You can search for a physician by specific characteristics, such as gender or language spoken. You can search for a hospital by location and name. Our website also contains information and interesting tools to help you better understand what you can do to improve your health. For example, our health risk assessment helps you assess your current health and determine risks. It also allows you to track your progress in improv- ing behaviors and lets you know when to obtain preventive services. Visit truehealthnewmexico.com/staying-healthy.aspx to get started. If you would like more information about these items, please call Customer Service at 855-769-6642 . The most recent information about True Health New Mexico, our services and coverage of drugs is always available on our website. OUR WEBSITE Your source for complete member information 2 { TRUE TO YOUR HEALTH } { M E M B E R B E N E F I T S }