You can change your Primary Care Physician (PCP) at anytime by calling Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). You can also request the change in writing. The effective date of the change will be first day of the next month after your request is received, provided you are not receiving hospital or other institutional care at the time of your request. You can file a claim by using the Medical Claim Reimbursement Form. You can contact Member Services at 408.885.4760 or 1.888.421.8444 or go to the Forms and Documents area under Members on our website to submit the form electronically. Please make sure your name, the Subscriber Social Security Number, date and type of service, your PCP’s name, and any other pertinent information are included in your request. You can submit the itemized bill and/or your original receipt showing proof of payment with your request for reimbursement within ninety (90) days after (or as soon as possible thereafter) you receive those Covered Services to: Valley Health Plan
Attn: Claims Department
P.O. Box 26160
San Jose, CA 95159-6160 VHP will process the request for reimbursement within forty-five (45) working days of receiving complete information. VHP may reimburse you or the Plan Provider, less any copayment, for the Covered Services. Prescription drug costs you incur for Out-of Network Emergency or Urgent Care services can be submitted for review and reimbursement on the Medical Claim Reimbursement Form along with the original receipt(s) to VHP Member Services. The form can be found under the Forms and Documents in the Members area of our website. You must submit your request within ninety (90) days from the date of service. If approved by the VHP Medical Director, you will receive a reimbursement for approved covered costs within forty-five (45) working days. You can contact Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for more information. If your employer covers dependents, your employer must offer coverage to your child dependents up to age 26, regardless of marital or student status. You must submit an enrollment or status change request to your Employer to add a new spouse or dependent(s). VHP must receive the request within thirty-one (31) days after they became your Eligible Dependent(s). You must provide proof of dependent status (e.g. birth or marriage certificate) when you add anyone to your Coverage. In the event of an emergency, call 9-1-1 or seek care at the closest hospital. It is an emergency if waiting to get care could be dangerous to your life or a part of your body. Urgent care is care you need within 24-48 hours. If you need Urgent Care services, go to a VHP Network Walk-In Urgent Care clinic. Find the closest Urgent Care clinic to you by using our online Provider Search or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).
In the event you are out of Santa Clara County, go to the closest Urgent Care Clinic. All follow-up care must be received through your PCP or authorized by VHP. Valley Health Plan (VHP) covers worldwide Emergency and Urgently Needed Services. When you travel outside of the Santa Clara County, coverage must be authorized by VHP. If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify Valley Health Plan. In other cases, you should contact your PCP within 48 hours after receiving emergency care. You are covered for urgent care you receive when traveling. You are encouraged to contact your PCP so they can provide or arrange for any follow-up care that you may need. In the event you are outside of Santa Clara County and cannot safely go to your providers, go to the closest Urgent Care provider. All follow-up care must be received through your PCP or authorized by VHP. Yes, vaccinations will be covered by VHP through the Plan Pharmacies. Check Plan Pharmacy for vaccination service and requirements. As a VHP Member, there are many ways to get your FREE flu vaccine! - Schedule a flu vaccine appointment with your PCP
- Ask for the vaccine at your next doctor’s visit
- Show your VHP ID card at any Plan pharmacy that provides the flu vaccine
- Safeway Pharmacies
- Walgreens Pharmacies
- Gardner Family Health Network Pharmacies
- South County Health Center
7526 Monterey Street
Gilroy, CA 95020
Pharmacy: 408.848.9494 - St. James Health Center
55 East Julian Street
San Jose, CA 95112
Pharmacy: 408.918.2612
- Palo Alto Medical Foundation (PAMF) Pharmacies
- Mountain View Center
701 E. El Camino Real
Mountain View, CA 94040Pharmacy: 650-934-7699
Hours: Monday – Friday, 9:00 am to 6:30 pm; Saturday, 9:00 am to 1:00 pm
- Palo Alto Center
795 El Camino Real, Lower Level A, Lee Building
Palo Alto, CA 94301
Pharmacy: 650.853.6066
Hours: Monday - Friday, 9:00 am to 6:30 pm; Saturday: 9:00 am to 1:00 pm
Leiter's Pharmacy- 1700 Park Avenue, Suite 30
San Jose, CA 95126
Pharmacy: 408.292.6772 or 800.292.6773
Hours: Monday - Friday, 9:00am to 6:30pm; Saturday, 9:00am - 6:00pm
Important Note: The are for VHP Members receiving care from providers at SCVMC, Valley Specialty Center & Valley Health Centers ONLY. No, over-the-counter drugs and supplies are not covered under the VHP pharmacy benefit plan. You can refill your prescription at any Plan Pharmacy in the United States. Any participating Plan Pharmacy can arrange for an additional one-month supply to be taken with you. If traveling outside the United States:
Any participating Plan Pharmacy can arrange for an additional one-month supply to be taken with you. Please contact Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free) for additional information. Please contact Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free), closed Thanksgiving and Christmas Day. The VHP Formulary, as well as information about which drugs need prior authorization, step therapy, and/or have quantity limits, can be found at www.navitus.com. For questions about the VHP Formulary and drug coverage, please contact Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free). Yes. A limited number of drugs will require a prior authorization. Drugs requiring a prior authorization have a PA next to them on your formulary. For more information about prior authorizations, visit www.navitus.com. Your provider submits the prior authorization request on your behalf. Navitus will review the prior authorization request within 5 business days of receiving complete information from your physician. If you have questions about non-formulary drugs, contact Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free). Yes, when filling prescriptions at your Plan Pharmacy, you are required to present your VHP ID card. In an emergency, you may need to request reimbursement for prescriptions that you have filled and paid for yourself. If your prescription is eligible, you may receive reimbursement. To submit a claim for reimbursement, you must provide specifi c information about the prescription, the reason you are requesting reimbursement, and any payments made by primary insurers. Complete the appropriate claim form and mail it along with the original receipt to: Navitus Health Solutions
Operations Division - Claims
P.O. Box 999
Appleton, WI 54912-0999 Claim forms are available at www.navitus.com or by calling Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free). A generic drug is a drug that is the same as a brand name drug in dosage, safety, strength, how it is taken, how it works in the body, quality, performance and intended use. Typically, generic drugs are less expensive then their brand counterparts and can save you money by reducing co-pays or—in the case of over-the-counter drugs—by allowing less out-of-pocket expense at the cash register. Coordination of Benefits (COB) takes place when you have coverage under Navitus Health Solutions and another policy. One of the policies will be your primary coverage and one is your secondary coverage. Claims are first submitted to your primary policy and then to the secondary policy. The secondary policy covers the remaining cost of covered medications up to the allowed amount minus any applicable copayment. At the pharmacy, prescriptions are paid under your primary insurance. To be reimbursed by Navitus Health Solutions for your secondary coverage, you must complete a reimbursement form and submit it to Navitus Health Solutions. Reimbursement forms are available on the Navitus website, www.navitus.com or by calling Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free). Members who are taking specialty medications for certain chronic illnesses or complex diseases can receive the prescriptions through Specialty Plan Pharmacy. Your Plan Pharmacy will identify if your prescription is a specialty medication. - Navitus Specialty Rx (Diplomat) will accept prescriptions from all Plan Providers.
- Santa Clara Valley Medical Center (SCVMC) Plan Pharmacies will accept prescriptions from SCVMC Plan Providers ONLY.
For information on Specialty Prescriptions, please call Navitus Customer Care 24 hours/daily, at 1.866.333.2757 (toll-free). Prescriptions cannot legally be mailed from the mail order pharmacy or any pharmacy in the United States, to locations outside of the country, except for U.S. territories, protectorates and military installations. When you have a concern about a benefit, claim or other service, please call Navitus Customer Care, 24 hours/daily, at 1.866.333.2757 (toll-free). The Customer Care Specialists will answer your questions and resolve your concerns quickly. If your issue or concern is not resolved by calling Customer Care, you have the right to file a writt en appeal with Navitus Health Solutions. Please send this appeal, along with related information from your doctor, to: Navitus Health Solutions
Attn: Appeals Department
P.O. Box 999
Appleton, WI 54912-0999 Or fax to:
920.831.1930 Attn: Appeals Department If your issue or concern is not resolved by calling Navitus Customer Care, you can also contact VHP Member Services at 408.885.4670 or 1.888.421.8444 (toll-free). The Valley Health Plan formulary is on the Navitus Health Solutions website, www.navitus.com, under the Member portal. You will need to register to get a User ID and password. You may search the Valley Health Plan formulary for a specific drug, or browse alphabetically or by category of use. Also included is information about which drug products need Prior Authorization and/or have quantity limits. The formulary is available to you in full and as a quick reference. To enroll in Valley Health Plan as an Eligible Retiree, contact your employer. Your employer will give you the necessary paperwork, including the VHP application form. You must reside within the Service Area, San Francisco County, or any adjacent counties to the Service Area. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties. VHP offers over-the-phone language assistance at no cost to you! Call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll free) if you would like to talk to us in your language about any questions, comments or concerns. You can get an interpreter to talk to your doctor by contacting VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll free). As required by the Department of Managed Health Care (DMHC), VHP will provide written translation of any vital documents, such as applications, grievance or consent forms, or other important membership materials. Services are available through referral by your Primary Care Physician (PCP). If you seek care without Prior Authorization, you may be financially responsible for all charges. Coverage is limited to a maximum of twenty (20) visits per Calendar Year. You will be asked to pay a $10.00 co-payment at the time of each visit. Unauthorized services such as herbal medicines or other treatments will be your financial responsibility. For a list of our Acupucture Providers, you may use our online Provider Search or call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll free). Services are available through referral by your Primary Care Physician (PCP). If you seek care without Prior Authorization, you may be financially responsible for all charges. Coverage is limited to a maximum of twenty (20) visits per Calendar Year. You will be asked to pay a $10.00 co-payment at the time of each visit. For a list of our Chiropractic Providers, you may use our online Provider Search or call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll free). Yes, vaccinations will be covered by VHP through the Plan Pharmacies. Check Plan Pharmacy for vaccination service and requirements. Travel Immunizations as recommended by the U.S. Preventive Services Task Force are available. To obtain your travel immunizations, you can: - Contact your Primary Care Physician (PCP)
- Call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for more information
- Check with your Plan Pharmacy to see if the immunization you need is available
Go to the Travel Clinic: Santa Clara County Public Health Department
Immunization Clinic
976 Lenzen Avenue
San Jose, CA 95126 Walk-In hours (408.792.5200) - Monday, Tuesday, Wednesday, Friday 8am-11:30am
- Thursday 8am-11am
- Friday 1pm-4:30pm
Valley Health Plan (VHP) covers worldwide Emergency and Urgently Needed Services. When you travel outside of the Santa Clara County, coverage must be authorized by VHP. If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify Valley Health Plan. You are covered for urgent care you receive when traveling. You are encouraged to contact your PCP so they can provide or arrange for any follow-up care that you may need. In the event you are out of Santa Clara County and cannot safely go to your providers, go to the closest Urgent Care provider. All follow-up care must be received through your PCP or authorized by VHP. |
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