Benefits & ServicesOur goal is to help you maintain good health. That is why Banner – University Family Care/AHCCCS Complete Care (BUFC/ACC) offers our members a variety of benefits & services.
Case & Disease Management
Case management is a benefit BUFC/ACC offers to you. Our goal is to help you be healthy. A case manager will help you get the services you need to keep you healthy. They will work with you and your PCP to coordinate your care. For more information please call and ask about Case Management at (800) 582-8686.
Disease Management is another service offered at no cost to BUFC/ACC members. If you have a health problem such as diabetes or asthma, or if you are looking for ways to stay healthy, our Disease Managers are here to help you. Please call and ask about Case Management at (800) 582-8686 for more information.
BUFC/ACC members ages 20 and younger are assigned to a Dental Home, also known as a Primary Dental Provider (PDP). A Dental Home is a dentist's office that is visited every six months for a check-up.
All dental health checkups, cleanings and treatments are covered for BUFC/ACC members ages 20 and younger.
Children do not need to be referred by his/her PCP to see a dentist.
At 12 months of age, children should begin to see a dentist for a checkup every six months. BUFC/ACC sends dental checkup reminders. Dentists can help prevent cavities. They can use dental sealants (a coating painted on the back teeth) and fluoride treatments. Dentists also teach you and your child how to care for teeth. It is important for your child to go to the dentist every six months.
Look in the BUFC/ACC Dental Provider Directory to choose a dental clinic near you or call our Customer Care Center for help scheduling a visit.
Use these guidelines for scheduling appointments for your child:
- Emergency dental appointments - same day appointments; for extreme pain and dental emergencies
- Urgent dental appointments - within 3 days for lost fillings, broken tooth
- Routine dental appointments - within 45 days, for routine checkups and dental cleanings
- Make sure you take your child's BUFC/ACC ID card with you to the dental appointment
Any member age 21 years and older can only receive emergency dental services if you have a need for care immediately, like a bad infection in your mouth or pain in your teeth or jaw.
Pre-transplantation members may also get treatment for oral infections, oral disease, periodontal disease, medically necessary extractions, and simple restorations like a filling or crown. Call our Customer Care Center to see if you have been approved for your transplant before you seek dental care.
Well-Child Care / Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
BUFC/ACC wants to help your children grow up healthy. Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21.
The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid members in effectively utilizing these resources.
EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS recipients less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law 42 USC 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS state plan.
Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDT services.
A well-child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and dental periodicity schedules.
Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening services, vision services, dental services, hearing services and “such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the (AHCCCS) state plan.
This means that EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within one of the 29 optional and mandatory categories of “medical assistance” as defined in the Medicaid Act. Services covered under EPSDT include all 29 categories of services in the federal law even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective.
EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive, and rehabilitative services. However, EPSDT services do not include services that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions.
EPSDT/Well-Child Visits Include:
- A comprehensive health and developmental history, including growth and development screening which includes physical, nutritional and behavioral assessments
- Nutritional Assessment provided by a PCP
- Behavioral Health Screening and services provided by a PCP
- Developmental Screening Tools used by a PCP
- A comprehensive unclothed physical examination
- Appropriate immunizations according to age and health history
- Laboratory tests including blood lead screening assessment and blood lead testing appropriate to age and risk. Required blood lead screening for children under six years of age is based on the child's risk as determined by either the member's residential zip code or presence of other known risk factors
- Health education, counseling, and chronic disease self-management
- Appropriate oral health screening, intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician assistant or nurse practitioner
- Appropriate vision, hearing and speech screenings
- TB testing as appropriate to age and risk
- Eye examinations and prescriptive lenses
- Ocular Photoscreening for children ages 3-5 is covered when due to challenges with a child's ability to cooperate with traditional vision screening techniques. Limited to lifetime coverage of 1
- Medicines listed in the BUFC/ACC Drug Formulary
- Special medical foods when medically necessary
Well-Child Care Will Also Give You Ideas About How to:
- Keep your child well
- Protect your child from getting hurt
- Spot health problems early
- Apply for services like WIC, Head Start, Children's Rehabilitative Services (CRS), and the Arizona Early Intervention Program (AzEIP).
If you need medicine, your provider will choose one from our list of covered drugs and write you a prescription. Ask your doctor to verify that the medication is on the BUFC/ACC list of covered drugs.
If the medicine your provider feels you need is not on our list and you can't take any other medication except the one prescribed, he/she may request prior authorization from BUFC/ACC.
Some over-the counter medicines are also covered when a prescription is written by your doctor. All prescriptions should be filled at a pharmacy listed in the Pharmacy Directory. If you have other insurance, BUFC/ACC will only pay the copays if the drug is also on the BUFC/ACC drug list.
To help you get your prescription more easily, your provider can send your prescription electronically to the network pharmacy of your choice. This way, it will be ready when you arrive at the pharmacy.
WHAT YOU NEED TO KNOW ABOUT YOUR PRESCRIPTION
Your provider may give you a prescription for medication. Be sure and let him/her know about any medications you get from another provider. Also mention medications you buy on your own including non-prescription or herbal products.
Carefully read the drug information the pharmacy will give you when you fill your prescription. It will explain what your medicine is for and possible side effects. If you do not understand how to take your medicine or why you should take it, ask to speak to the pharmacist.
WHAT HAS CHANGED FOR DUAL-ELIGIBLE MEMBERS?
BUFC/ACC covers drugs which are medically necessary, cost effective and allowed by federal and state law.
For BUFC/ACC recipients with Medicare, BUFC/ACC does NOT pay for any drugs eligible for coverage by Medicare or for the cost-sharing (coinsurance, deductibles and copayments) for drugs available through Medicare Part D, even if the member chooses not to enroll in the Part D plan.
The label on your medication bottle tells you how many refills your provider has ordered for you. If your doctor has ordered refills, you may only get one 30-day refill at a time.
If your provider has not ordered refills, you must call him/her at least five (5) days before your medication runs out. Talk to your provider about getting a refill. The provider may want to see you before giving you a refill.
WHAT SHOULD I DO IF THE PHARMACY DENIES MY PRESCRIPTION?
Call our Customer Care Center and we can help you find out why your prescription is not approved to fill. Sometimes, a primary insurance may be entered wrong or it may be too soon to refill. Other times the medication is not on our list of covered drugs. If a pharmacy turns you away or will not fill your prescription, ask if you and/or the pharmacist can call Customer Care Center together to find out what is happening. We will work with you and the pharmacy to find the best options for you. When you call for help before leaving the pharmacy, we can try to take care of the problem so you will not need to make another trip. We want to make it easy for you.
EXCLUSIVE PHARMACY AND PROVIDER ASSIGNMENT
Members who are taking certain medications are reviewed to make sure that it is the right medication at a safe dose. Some of the medications that are included in this review are:
- Opioids (for pain)
- Benzodiazepines (for anxiety)
- Muscle relaxants
- Hypnotics (for sleep)
- Atypical antipsychotics
This review occurs every three months. Members may be limited to one pharmacy and/or one provider for these medications. Some of the reasons why this would occur include:
- If you fill four or more different types of these medications, have four or more doctors prescribing these medications, and use four or more pharmacies to fill these medications within three months
- You fill 12 or more prescriptions for one of these medications within three months
- A forged or altered prescription is used at the pharmacy
Assignment to a specific provider or pharmacy is in place for 12 months. It will then be reviewed to see if it is still needed. You would be notified in writing before this assignment occurs. You will have the right to appeal this decision. If you are assigned to a specific provider and/or pharmacy and need a medication in an emergency situation, you can contact BUFC/ACC's Customer Care Center at (800) 582- 8686 to help with this.
You may be excluded from this requirement if you have certain conditions including:
- You are in hospice care
- You are in a skilled nursing facility
Some medical services and specialists need prior approval by BUFC/ACC. If they do, your PCP must arrange for prior authorization for these services. BUFC/ACC must review these requests. Your PCP's office will let you know if your prior authorization request is approved. You can also call our Customer Care Center to find out the status.
If your PCP's request is denied, BUFC/ACC will let you know by mail. If you have a question about the denial, you may call our Customer Care Center. You can also write to us at the address listed on the front of this handbook. Please see page 76 for more information about filing an appeal for a denied authorization. The appeal decision sent by BUFC/ACC will also tell you how to request a State Fair Hearing.
If you need services not covered by BUFC/ACC, due to moral or religious obligations, please contact our Customer Care Center for help.
Behavioral Health Services
If you feel that you need help with an emotional, alcohol or drug problem, you do not need a referral. For non-emergency help, you may call the following people:
- Your PCP
- BUFC/ACC Customer Care Center at (800) 582-8686
- BUFC/ACC Behavioral Health Care Manager of the day during business hours
You do not need a referral from your PCP for the following services:
- Emergency Services
- Behavioral Health issues
- OB/GYN services
- Dental services
The care listed below will be covered through BUFC/ACC. Some services may have limitations and/or require a prior authorization, contact our Customer Care Center for more information:
- Ambulance for emergency care
- Behavioral Health Care
- Care while you are pregnant
- Care Management
- Checkups for children, pregnant women, Qualified Medicare Beneficiary (QMB), and Seriously Mentally Ill (SMI) members
- Children's services including routine dental care
- Chiropractic services for children and QMB
- Emergency medical and surgical services related to dental (oral) care
- Disease Management
- Emergency Dental
- Emergency or Urgent Care medical treatment
- Eyeglasses or contacts for children, or adults only after cataracts are removed;
- Family planning / birth control
- Health care services through screenings, diagnosis and medically necessary treatments for members 21 years of age or older
- Hospice care
- Hospital care
- Lab work and x-rays
- Medical tests
- Medically needed foot care performed by a licensed podiatrist; a podiatrist may provide foot care for members when ordered by a PCP or other provider
- Medicine from the approved drug list, the BUFC/ACC Drug Formulary
- Organ transplants
- PCP office visits
- Preventative and routine gynecological services for female members (no referral needed)
- Transportation to health care visits
- Speech, Physical and Occupational Therapies
- Second opinions: You have the right to have a second opinion from a qualified health care professional within the network. If one is not available in the network, you have the right to request a second opinion outside the network at no cost to you
- Supplies and equipment, including BUFC/ACC Drug Formulary diabetic testing equipment and supplies
- Well-child checkups including dental, hearing, shots and vision care
Your PCP may want you to see a specialist or get special services. He/she will arrange for the special care listed below. Some of these may require prior authorization from BUFC/ACC:
- Diet and health teaching
- Home health care
- Organ transplants
- Skilled nursing home care
- Rehabilitation services like physical and occupational therapy, or speech therapy (for members 20 years and younger)
- Specialist care
- Social Services
Tobacco Education and Prevention
The BUFC/ALTCS Tobacco Cessation Program offers a number of nicotine replacement products. This includes patches, lozenges, gum, and medications to help you quit tobacco. When you and your doctor decide which is best for you, a twelve week supply is available by prescription every six months as needed. Only one product can be selected at a time. Members also have no cost telephone support from the Arizona Smoker's Hotline (ASHLine). ASHLine is sponsored by the Arizona Department of Health Services and Prevention Program (ADHS-TEPP). ASHLine can help you at no cost by setting a quit date and giving you support. If you would like more information about quitting tobacco, please call the ASHLine at (800) 556-6222. Or visit their website at www.ashline.org.
Freedom From Smoking - American Lung Association: www.lung.org. This is a program to help adult smokers quit.
Freedom From Smoking® is available as a group clinic, an online program and a self-help book. Talk to a cessation counselor at the Lung HelpLine at 1-800-LUNGUSA (1-800-586-4872).
You have a medical emergency when your life, body parts or bodily functions are at risk. This can be a damage or loss of function to you unless immediate care is received. In cases of emergency call 911. A taxi will not transport you to the emergency room.
A ride to an appointment for a service that is covered by BUFC/ACC.
Call our Customer Care Center and select the transportation option. Call at least 72 hours before your scheduled visit. Same day transports may not always be available. Call in advance due to the number of transportation vehicles in all counties.
On weekends and holidays, you can call our Customer Care Center for taxi rides to urgent care centers when you are sick. Always remember to dial 911 if it is a medical emergency.
WHEELCHAIR OR STRETCHER
If you need a wheelchair accessible vehicle, make sure to tell us. If you have stretcher needs, please be sure to specify that when making the request.
CHILDREN, COMPANIONS, OR ESCORTS
BUFC/ACC allows member and one additional passenger per transport. More than one more passenger is allowed if that person is a minor, if the person is under the care and supervision of the member or has a medical condition. If the member is a single caregiver with more than one minor child in his/her care, BUFC/ACC allows other minor children to be transported. Not all taxis can accommodate more than 3 passengers. You will need to provide your own car seat for any child passengers.
IF YOU CALL TO GET A RIDE TO A MEDICAL APPOINTMENT, PLEASE BE READY TO TELL THE REPRESENTATIVE THE FOLLOWING
- Your name, AHCCCS ID number, date of birth, address, phone number (for verification purposes)
- The date, time, and address of your medical visit
- If you need a ride one way or a round trip
- Your travel needs (wheelchair, stretcher, or other)
- Any special needs (oxygen, IVs, someone who needs to travel with you, an extra-wide or electric wheelchair, a high-top vehicle, etc.)
- Children under the age of 5 require a car seat
CANCELING RIDES TO YOUR APPOINTMENTS
If you cancel your doctor or dentist visit, you must also call our BUFC/ACC Customer Care Center to cancel your ride to your visit.