Download GATEWAY TO Are You Getting Enough Sleep?

A Newsletter for
Gateway HealthSM Members
G AT E WAY TO
Are You Getting
Enough Sleep?
PAGE 1
MARCH 2015
HEALTH
Your Opinion Matters
to Gateway Health
In order for us to serve you better, Gateway HealthSM wants to know your
opinions because your feedback is valuable to us. Throughout the year, we
will reach out in different ways such as telephone, direct mail or e-mail to
understand how we can better your experience.
In addition to our own surveys, Gateway Health is required to take
part in national surveys that measure how we are doing as a health plan.
We encourage you to look through your mail as you may be
selected for the national survey from the Consumer Assessment of
Healthcare Providers and Systems (CAHPS®).
The survey measures how well we are meeting your expectations and
allows us to improve our performance. Your answers are kept secret and
have no effect on your benefits. Gateway only receives the final score and
confidential comments from the company that conducts the survey.
In the CAHPS survey you will be able to rate your experiences with
their physicians and health plan when obtaining care and service:
Getting
care
quickly
Rating of
personal
doctor and
specialist
How well
your doctors
communicate
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HEALTH
Table of Contents
Are you Getting Enough Sleep?
The HPV Vaccine
5
Connecting for Better Care
5
Spring Forward:
Healthy Recipes for You
6
Mom Matters: Pregnancy Fitness
for You and Your Baby
7
Did You Know?
7
Secondhand Smoke Hurts Everyone
8
Your Member Services Team:
Quality is Our Priority
9
Drugs, Alcohol and Domestic Abuse
9
10-11
Making Medical Decisions
in Advance
11
Spring Allegies and Asthma:
How to Survive the Sneezy Season
12
What is a Formulary?
13
Getting the Care You Need
Coordination
of care
14-15
The Doctor-Patient Relationship:
What’s Up Doc?
16
24-Hour Nurse Line Now Available
16
2015 HealthChoices Meetings
17
Important Phone Numbers
If you receive a survey in the mail, we encourage you to take the
time to fill it out and return it. Your participation is the first step in
getting the care you deserve.
1
Living Well with Chronic Conditions 2-5
Living With Diabetes:
Understanding Insulin
Rating your
health plan
Are you getting
enough sleep?
G AT E WAY TO
Back Cover
Z
Sleep is important because it’s your
body’s way of resting and recharging
for the next day. Without proper
rest, many are at an increased risk for
memory loss, headaches and overall
stress. This can be attributed to society’s
hectic lifestyle which may include longer
work hours and access to 24/7 cable TV,
as well as too much nicotine, caffeine
and alcohol. According to the National
Sleep Foundation, nearly one-third of
Americans are not getting enough sleep.
Research has found that lack of sleep
can lead to all sorts of health problems,
including heart disease, diabetes, obesity
and depression. For those with existing
health conditions, lack of sleep will make
these conditions much more difficult to
manage and could lead to complications.
“Sleep is not a luxury, it’s a necessity
and should be thought of as a vital sign
of good health,” says Wayne Giles, M.D.,
National Center for Chronic Disease
Prevention and Health Promotion.
Recent reports of highway and
industrial accidents, as well as medical
errors, can also be traced to lack of sleep.
So what can you do to be certain you are
getting your 40 winks?
Z
5 Tips to Get Your ZZZZs:
• Go to bed at the same time each night and rise the same time each morning.
• Sleep in a quiet, dark and relaxing environment, which is neither too hot nor too cold.
• Make your bed comfortable and use it only for sleeping and not for other activities, such as reading, watching TV or listening to music.
• Avoid large meals or snacks before bed. This includes alcohol such as beer, wine and liquor. • Exercise for better sleep? You betcha! The National Sleep Foundation says exercise actually helps people fall asleep faster and stay asleep by releasing tension.
One trend that affects sleep is the nation’s
growing use of electronics and using them
24/7. Technology is great, but it comes with
a downside. Experts recommend avoiding
extra screen time before bed. This includes
the TV, computer, video games and handheld devices. While you may find them
relaxing, these actually stimulate the brain,
making it harder for you to fall asleep.
Z
Z
AGE SPECIFIC
SLEEP GUIDELINES
AGE
HOURS
NEWBORNS
16-18
PRESCHOOLAGED
CHILDREN
11-12
SCHOOLAGED
CHILDREN
AT LEAST
10
TEENS
9-10
ADULTS
7-8
For more information about sleep
and sleep disorders, visit the
National Sleep Foundation’s website at
www.sleepfoundation.org
MARCH 2015
••• A BETTER WAY
1
••• GATEWAY TO LIFESTYLE MANAGEMENTsm PROGRAMS
LIVING WELL WITH
CHRONIC CONDITIONS
CARDIAC For members age 21 or older.
Learn about:
• Simple ways to take care of your heart that will help you to live better.
• Better choices with diet and activity.
• Why certain medications are ordered and how they help you.
Here are some tips to follow if you have heart problems:
• Most heart medications have to be taken for life. Just because the prescription runs out does not mean
that you no longer need the medication. Be safe. Call your doctor and ask.
• Do not stop taking a pill! Call your doctor to see if and how you can SAFELY stop taking it.
COPD For members age 21 or older.
What do our programs offer?
• You may receive mailed newsletters.
• You may receive additional educational materials for your condition through the mail.
• You may receive health care reminder phone calls.
• You may receive telephonic support from specially trained case managers who will help you better understand
your condition.
• Gateway has a nurse line available 24 hours a day. A nurse can help answer your questions and concerns.
The call is cost-free.
ASTHMA For members age 2 or older.
Learn about:
• How a controller medicine is different from a rescue inhaler.
• How to identify and avoid your asthma triggers.
• How to use an asthma action plan. This plan can help you when you are sick.
Here are some tips to keep your asthma under control:
• Take your long-term control medicine every day. It only works when you are taking it! • Tell your doctor if you need to use your rescue inhaler more than 2 days a week or if you are having
your medicines.
trouble breathing at night. Your doctor may want to review
2
DIABETES For members of all ages.
Learn about:
• Blindness, amputations and kidney problems.
• How taking your medications and testing your blood sugar as recommended by your doctor can help
you stay on top of your diabetes.
• How getting the following tests every year may catch problems even before you have symptoms.
• Urine test (microalbumin) – a simple urine test that checks for small amounts of protein in the urine.
Protein in the urine can be an early indicator of kidney problems.
• A1C – a blood test that measures your average blood sugar for the past 2-3 months. It doesn’t
replace checking your own blood sugar, which tells you what your blood sugar is only at the time
you are checking.
• LDL-C (cholesterol) – a form of fat that can lead to a buildup of cholesterol in the arteries.
Controlling your LDL as advised by you healthcare provider is the most effective way to protect the
heart and blood vessels.
• Dilated Retinal Eye Exam – an exam where the doctor puts drops in your eyes to make the pupils
big so the retina can be checked.
MARCH 2015
Having a chronic health problem doesn’t mean you can’t live an active life and we’re here to help! Gateway HealthSM
welcomes you to participate in our Gateway to Lifestyle ManagementSM Programs. Participation in our programs is
voluntary and at no additional cost.
Learn about:
• How a controller medicine is different from a rescue inhaler.
• How to identify and avoid your asthma triggers.
• How to use an asthma action plan. This plan can help you when you are sick.
Here are some tips to keep your asthma under control:
• Take your long-term control medicine every day. It only works when you are taking it! • Tell your doctor if you need to use your rescue inhaler more than 2 days a week or if you are having
trouble breathing at night. You may need more medicine.
• Call your doctor right away if you develop any of the following symptoms:
• Increased shortness of breath or wheezing
• Increased cough
• Mucus is thicker or changes color
• Fever
3
In the MOM Matters® program learn about:
• How we can support you by referring you to community services.
• Signs of preterm labor and of a normal pregnancy.
• How we can arrange for a nurse to visit you in your home before or after your baby is born.
Here are some helpful tips to have a healthy pregnancy:
• Keep all prenatal appointments. If you miss an appointment do not skip it, call your doctor to reschedule.
• Take prenatal vitamins as prescribed by your doctor.
• Never take prescribed or over-the-counter medications without first checking with your doctor.
• Do not drink alcohol, use illegal drugs or smoke.
• Do not be around people who smoke. Secondhand smoke can harm you and your baby.
• Eat at least three healthy meals a day.
• Drink at least six to eight glasses of water daily.
• Brush teeth and floss every day. Mouth and gum infections can increase your risk of preterm labor.
• Wear your seat belt. Wear the lap portion low under your belly so it touches your thighs.
If you would like more information about a Gateway to Lifestyle Management
program call 1-800-642-3550. TDD/TTY 711 or 1-800-654-5984.
Case managers are available Monday – Friday, 8 a.m. to 5 p.m.
If you or your child has asthma, diabetes, COPD or heart disease, you are
already enrolled with your membership in Gateway Health. If at any time you
wish to stop participating in the program, please call the number listed above.
Para información en español sobre estos Programas, por favor llame a
1-800-642-3550 y marque el número 6.
Gateway Health’s member
portal is now live! The portal
is customized to meet your
needs, keep you healthy
and take control of your
own health care. At Gateway
Health, we think of you as a
valued member of our team.
When you play an active role
in your health care, you can
improve the quality of your
health. It’s your personal way
to understand your health,
improve it and partner with
your doctors.
If there were a
vaccine against
cancer, wouldn’t
you get it for
your kids?
Logon is simple
Registration is free, quick
and simple. Members have
the convenience of secure,
24/7 access to the tools and
information available on
GatewayHealthPlan.com.
The online service will be
secure and have measures
in place to protect your
privacy by having you or your
caregiver submit both a user
name and password when
you log on.
HPV vaccine is
cancer prevention.
Talk to the doctor
about vaccinating
your 11–12 year old
Advantages to using
the new member
portal:
sons and daughters
against HPV.
General health tips:
• Everyone with a chronic health condition should get a yearly flu shot.
• Remember to take your medicine the way your doctor ordered. If you cannot take them for any reason,
call your doctor.
• Visit your doctor at least twice a year. Your doctor needs to see you to make sure your condition is under
control so that you can do the things you like to do.
• Stop smoking and avoid secondhand smoke. Get help to quit smoking by calling 1-800-QUIT-NOW
(1-800-784-8669).
• If you are discharged from the hospital, make sure you completely understand your discharge instructions.
• Call your doctor when you get home from the hospital. It is important that you see your doctor within two
weeks after you get home.
• Gateway has a website with valuable health information. http://www.GatewayHealthPlan.com
4
• Find a doctor, hospital
or specialist within your
network
• Find a pharmacy
• Email Member Services
• Request a new
member ID card
www.cdc.gov/vaccines/teens
Technical Support?
Distributed by:
CS249586-A
Contact Member Services
if you need information in
a language other than
English or in another
format. Pennsylvania
Medicaid: call 1-800-3921147. TTY users phone
(711) or 1-800-654-5988.
MARCH 2015
PREGNANCY For pregnant members.
CONNECTING
for better
care
5
••• mom matters
Healthy recipes for you
Enjoy the fresh flavors of the season with healthy meals that incorporate the vegetables of spring.
Baby beets, asparagus, artichokes, morels and more—there’s fresh garden bounty and seasonal recipes to
remind you that spring has sprung.
Try this delicious spring pasta with fava beans and peas. The vibrant colors of spring shine in this
seasonal pasta dish. Choose firm, bright fava bean pods free of black marks—avoid pods on which the
outline of the beans inside is pronounced, indicating older favas.
Ingredients
•
•
•
•
•
•
•
•
•
•
•
1/2 cup shelled fava beans (about 1 3/4 pounds unshelled)
6 ounces uncooked campanelle or farfalle (bow tie pasta)
2 tablespoons extra-virgin olive oil, divided
6 center-cut bacon slices, cut into 1/2-inch pieces
1 1/2 cups sliced red onion
8 garlic cloves, sliced
3 ounces thinly sliced mushrooms
1 cup fresh shelled or frozen green peas, thawed
2 teaspoons fresh lemon juice
1/4 teaspoon kosher salt
1 1/2 ounces fresh pecorino Romano cheese (about 6 tablespoons), grated and divided
• 1/2 cup torn basil leaves
Preparation (PREP TIME IS 30 Minutes)
1. Place fava beans in a large pot of boiling water; cook 1 minute. Drain; rinse with cold water. Drain well. Remove tough outer skins from beans.
2. Cook pasta according to package directions, omitting salt and fat; drain.
3. Heat a large nonstick skillet over medium-high heat. Add 1 tablespoon oil to pan; swirl to coat. Add bacon; sauté 3 minutes or until bacon begins to brown. Add onion and garlic; sauté 3 minutes
or until vegetables are tender. Add mushrooms; sauté 3 minutes or until mushrooms begin to brown.
Add fava beans and peas; sauté 2 minutes. Stir in remaining 1 tablespoon oil, pasta, juice, and salt;
cook 2 minutes or until thoroughly heated. Remove pan from heat. Stir in 3 tablespoons cheese.
Divide pasta mixture evenly among 4 bowls, and top evenly with remaining 3 tablespoons cheese
and basil. Serve immediately.
Nutritional Information
Serves: 4, Amount Per Serving: ¾ cups, Calories: 371, Fat: 13.2g, Saturated fat: 4.2g, Monounsaturated
Fat: 5g, Polyunsaturated Fat: 1g, Protein: 16.2g, Carbohydrate: 48.3g, Fiber: 5.8g, Cholesterol: 19mg,
Iron: 3.2mg, Sodium: 521mg, Calcium: 127mg
6
For most women, exercise during pregnancy is important to do. However, the
physical changes of pregnancy may interfere with some forms of physical activity and
should be modified to accommodate your growing belly. Pregnant women should
always check with their health care provider before beginning or continuing any
exercise program. Your provider will need to evaluate any medical and/or pregnancy
risks that might change the type of exercise program recommended. The safest exercises are usually walking, swimming, indoor stationary
bicycling and low-impact aerobics. By making the time for exercise,
you may ease some of the pain and discomfort of both pregnancy
and delivery. Light workouts may also relieve stress and help you
relax during labor.
10 Tips for Exercising While Pregnant
• Drink plenty of water before, during and after
exercise to keep hydrated.
• Exercise in a safe environment and avoid
jogging on streets or open roadways.
• Don’t engage in high impact sports that could
harm your baby.
• To prevent a pulled muscle, always stretch
to warm up and cool down
• Wear comfortable clothing and shoes with
proper tread.
• Avoid overheating and slow down if you
feel short of breath.
• During yoga, make sure you have a skid
resistant floor mat or towel. If a pose is too
difficult, do a modified version.
• Get enough sleep so you are not too tired.
• Find a buddy to exercise with to help motivate
and keep you on schedule.
• Look for “mommy and me” exercise classes
nearby that are tailor made for pregnant and
postpartum women. Check with your OB/GYN
who can help you locate a nearby class. Most
women’s hospitals do offer them.
article source: Web MD
Did
You
Know?
Gateway Health
also offers four
Medicare Special
Needs Plans for
individuals who
qualify for both
Medicare and
Medicaid!
These plans include
Chronic Care
Special Needs Plans
(C-SNPs) for those
with the following
conditions: diabetes,
cardiovascular
disorder, or chronic
heart failure.
You may be eligible
for Medicare at
age 65, or under
age 65 with certain
disabilities.
Once you become
eligible for Medicare,
call 1-877-GATEWAY
(1-877-428-3929)
to learn more about
your Medicare
enrollment options
or visit us online
at www.
MedicareAssured.com.
MARCH 2015
SPRING FORWARD
PREGNANCY FITNESS
FOR YOU AND YOUR BABY
7
Secondhand
smoke hurts
everyone
Some of the cancer
causing chemicals
found in secondhand
smoke:
CARBON MONOXIDE
found in car exhaust
FORMALDHYDE
used for embalming
BENZENE
found in gasoline
POLONIUM 210
radioactive and very toxic
BUTANE
used in lighter fluid
Ammonia
used in chemical weapons
Vinyl chloride
used to make pipes
8
Did you know? Tobacco smoke
contains a deadly mix of more than
700 chemicals1. Hundreds are toxic
and about 70 of those chemicals can
cause cancer. While it is dangerous for
anyone who breathes it in, think of what
that secondhand smoke does to the
developing lungs of an infant or child?
Over time, this can lead to serious lung
problems such as asthma, allergies and
shortness of breath.
Secondhand smoke is the
combination of smoke from the burning
end of the cigarette and the smoke
breathed out by smokers. When someone
breathes in secondhand smoke, it is like
that person is smoking. Secondhand
smoke also irritates the eyes, skin, nose
and throat.
Unfortunately, the home is often
the place where children are most likely
exposed to secondhand smoke. Children
who live in homes where smoking is
allowed have higher levels of breathing
problems than kids who do not. Children
of parents or guardians who smoke are
also more likely to become smokers
themselves as teens and adults.
Babies whose mothers smoke while
pregnant are at a much higher risk for
birth defects and low birth weight.
Breathing secondhand smoke is a known
cause of sudden infant death syndrome
(SIDS) of infants before age one. Schoolaged children of parents who smoke often
have frequent bouts of bronchitis, ear
infections and have trouble participating
in sports due to chronic breathing
problems2.
The best thing you can do to
protect your family is to quit smoking
altogether. Ask people not to smoke
in your home or car. Make sure your
children’s caregivers do not smoke
around the kids and avoid indoor
places where people do smoke.
Ready to quit?
Call the Pennsylvania Free Quitline at
1-800-QUIT-NOW (784-8669).
Since 2010, the PA Quitline has helped
more than 15,000 Pennsylvanians
make an attempt to quit. Additional
information is available at the
Pennsylvania Department of Health’s
website at http://www.portal.state.
pa.us/portal/server.pt/community/
smoke_free/14315/tobacco_
prevention_and_control_programs_
home/557661
article sources:
Tobacco Free America, 2CDC Website
secondhand smoke and tobacco use
1
Our first priority in the
Gateway Health Member
Services department is to
provide excellent and efficient
customer service. We strive
to answer every call in a
courteous manner and go
above and beyond in our
attempts to provide exceptional
service to all of our members.
We work to quickly resolve any
concerns that our members
have and direct them to the
correct department when
necessary. Among the services
we provide are:
• Assistance finding
providers who take the
plan
• Ordering ID cards
• Answering questions about
medical benefits
Feel free to contact us anytime
from 8:00 a.m. to 8:00 p.m.
Monday through Friday at
1-800-392-1147. TTY users:
(711) or 1-800-654-5984.
When you call Member
Services, you may notice that
we give you reminders for
physical exams. We know life
is busy and it’s easy to forget
to see your doctor, unless you
are not feeling well. We remind
you to get these screenings
because it’s important to have
an established doctor-patient
relationship if you do get sick.
We may also remind you about
mammograms and other
screenings. It’s also important
to get your preventive exams
to catch potential problems
before they become real
problems.
9
Drugs, Alcohol and
Domestic Abuse
Drugs and alcohol do not cause domestic abuse. Some people use drugs and
alcohol when they abuse. Some victims may use drugs and alcohol to cope with
the effects of abuse. Injuries may be greater when drugs and alcohol are involved
in abuse.
Abuse may happen whether or not drugs or alcohol are involved.
Domestic abuse may include:
• Physical abuse
• Emotional abuse
• Keeping a person from having or making money
• Keeping a person from seeing friends and family
• Keeping the person from seeing a doctor
An abusive person may try to say that they hurt the victim, because he or she was
drunk or high. When alcohol and drugs are involved an abusive person may:
• Get a victim to use or become addicted to drugs or alcohol
• Buy drugs or alcohol for the victim
• Force the victim to sell drugs
• Force the victim to use drugs or alcohol
• Keep the victim from recovery options
• Blame the victim for the abuse because of alcohol or drug use
• Force the victim into prostitution for drugs or money
Drug and alcohol abuse are separate from
domestic abuse. However, each problem can
make the other worse.
To find the domestic abuse program
nearest you, visit http://pcadv.org and click
on Find Help or use the Find Help map on
the home page.
To reach the National Domestic Violence
Hotline call 1-800-799-SAFE. For TTY
1-800-787-3224.
To reach the National Substance Abuse Hotline
call 1-800-662-HELP (4357) or visit http://
www.samhsa.gov/find-help/national-helpline.
MARCH 2015
Your Member
Services Team:
Quality is Our Priority
9
understanding insulin
To help lower your
blood sugar your doctor
may give you pills and
recommend lifestyle
changes such as exercise
or diet.
Your body needs insulin to help the energy from the food you eat get into your cells. The cells use the sugar in blood as fuel to do their work. Insulin also helps the body
store fat for future energy use.
When you have type 1 diabetes, your body doesn’t produce insulin. When you
have type 2 diabetes, your body doesn’t make enough insulin or your body isn’t
using the insulin properly. This is known as insulin resistance.
Talk with your doctor about what type of diabetes you have and how often you
should test your blood sugar. Writing down your blood sugar results is important.
It helps your doctor decide what type of medication you need and amount you need.
To help lower your blood sugar your doctor may give you pills and
recommend lifestyle changes such as exercise or diet. Your doctor may even talk to
you about insulin.
Insulin comes in different types, based on:
• How long it takes to start lowering blood sugar, called “onset”.
• When its effect is strongest, called the “peak”.
• How long its effect lasts, called “duration”.
Diabetes
Body doesn’t produce
insulin
TYPE 2
Diabetes
Body doesn’t make
enough insulin or body
isn’t using the insulin
properly
starts
working
within
PEAKS IN
Rapid acting
(Aprida; Humalog/Humalog Mix;
Novolog/Novolog Mix)
5
minutes
about 1
hour
2-4
hours
Regular/short acting
((Humulin R U-500))
30
minutes
2-3
hours
3-6
hours
Intermediate–acting
(NPH)
2-4
hours
4-12
hours
12-18
hours
Insulin analogues
(Lantus/Levemir)
2-4
hours
works fairly
evenly
24
hours
type of insulin
LASTS
The Gateway to Lifestyle Management Program allows you to receive telephonic
support from specialty trained care managers who will help you understand your
condition. The program is voluntary and has no additional cost for Gateway Health
members.
Care managers are available to help Monday through Friday, between 8:30 a.m.
to 4:30 p.m. For additional information call 1-800-642-3550 and press Option #3.
Diabetes Support through Texting:
* This is only a sampling of insulin offered by Gateway Health. Please check with your healthcare
provider to determine which type of insulin and medication regimen is best for you.
10
If you or someone you know has diabetes,
Gateway Health has additional resources
available:
Gateway To Lifestyle ManagementSM
The following table explains some of the different types of insulins*:
TYPE 1
Ask your healthcare provider if you have any questions about insulin. People with
diabetes can also help control their blood sugar by eating a healthy diet, doing
moderate exercise and maintaining a normal weight.
Content adapted from the Nurse Practitioner Healthcare Foundation
Care4life is a personal diabetes support program with tips delivered right to your
phone. This six-month text messaging program, which is available in both English
and Spanish will help you learn to:
• Get personalized diabetes education
• Set and track blood glucose, weight and exercise goals
• Set reminders to take medication, log blood glucose and make appointments
There are two ways to sign up:
1. Go to https://www.care4life.com and click the “Sign Up Now” button. The
bottom of the form asks for an activation code. Simply enter: gateway.
2. Text the word JOIN to the number 300400. You will need to reply to the
welcome message with the sign-up code: gateway. And then reply to the next
text with your first name.
Have you completed your living
will or advance directive?
An advance directive (or living
will) is a legal document that lets
you choose how you want to be
treated if you become very ill.
You can make an advance
directive at any time and can
change your mind about what
your directive says.
This document will make
your family, friends and doctors
aware of the choices you would
like for your future medical care.
It is only used when you are
unable to tell those around you
what medical treatment you
would like to have. The advance
directive does not apply when
you are able to make your own
decisions. An advance directive
will not prevent you from
receiving care that you want.
Talk with your doctor and
loved ones about your choices.
The doctor can help you
determine what care you may or
may not want by explaining the
medical terms. You should give
your doctor and family a copy
of your advanced directive.
Having your wishes known
and honored can be a great
relief to your loved ones in times
of crisis.
Gateway HealthSM
can send you a free advance
directive. If you need
more information, call
the Care Management
Department at Gateway
Health at 1-800-642-3550.
MARCH 2015
LIVING with DIABETES
Storing Insulin
• The bottle of insulin being used should be kept at room temperature.
• Any insulin that will not be used in 30 days should be stored in the refrigerator.
• If a bottle kept at room temperature is not used within 30 days, throw it away.
• Do not store insulin in the freezer or in hot places, such as the glove box of a car
or on the windowsill.
• If your insulin is normally clear but has become cloudy, clumped, or crystallized, throw it away and open a new bottle.
• Have an extra bottle of insulin on hand.
• Do not share your insulin with others.
making medical
decisions in
advance
11
••• PHARMACY FACTS
How to Survive the
Sneezy Season
Soon the flowers will be blooming and the trees will
be budding. With spring comes pollen and allergies.
If you have asthma this can be a challenge. An asthma
controller medicine and careful planning can prevent
an asthma attack.
Take a minute to learn how you can take control of
your asthma!
Controller Medicines:
• Take your long-term control medicine every day! Never stop taking this medication unless your
doctor gives you special orders.
• If your doctor only recommended that you take a
control medicine during the spring and fall seasons,
then it’s important to start early. It can take up to a
month to get the full benefits from this medicine.
• Control medicines help decrease the swelling
in your lungs and help prevent asthma attacks.
Flovent, Advair, Pulmicort, Dulera, Symbicort,
Asmanex and Singulair are examples of control
medicines. Singulair is used to treat allergies.
12
5-10am
Time of day when pollen
counts are the highest.
Quick-Relief Medicine:
• A quick-relief medicine should be used during an
asthma attack because it works within a few minutes.
Always carry this medicine with you.
• This medicine helps to relax the muscles so you can
breathe easier. An example is a Ventolin inhaler. Ask
your doctor about using a spacer if you do not have
one. This helps to get more medicine to your lungs.
• Tell your doctor if you need to use your quick-relief
medicine more than two days a week. This may be a
sign that your asthma is not well controlled.
When pollen counts are high, start planning
• Pay attention to weather alerts. Pollen counts are the
highest between 5 a.m. and 10 a.m., so plan your
outdoor activities for later in the day.
• If you need to be outside when the pollen counts are
high, take a shower and wash your hair when you
come indoors, if possible.
• Avoid hanging your clothes outside on days when the
pollen counts are high.
• Keep your home and car windows closed.
• Use an air conditioner to cool down and keep the air
on recirculate so that you don’t pull in outside pollen.
• Use an air filter can help to decrease pollen exposure.
What is a Formulary?
A drug formulary is a list of drugs Gateway HealthSM
will pay for and is available for review on the Gateway
Health website. These drugs have been reviewed and
recommended by a team of doctors and pharmacists,
who form the Pharmacy and Therapeutics (P&T)
Committee, as well as the Department of Human
Services. This in-depth review ensures that Gateway
Health is providing you with quality, cost-effective
drugs to treat your medical condition.
In some cases drugs on the formulary are subject
to Prior Authorization, Step Therapy and/or a quantity
limit. If your medication requires prior approval, please
work with your medical provider to determine what
is needed to get your drug approved or changed to a
medication we cover.
What is a Prior Authorization?
Some drugs must be approved by Gateway before
you can get them at the pharmacy with only your
copayment. If a drug requires a Prior Authorization it
means it is either not on our formulary (also known
as a non-formulary drug) or there is specific clinical
information that your doctor must provide to assure
the drug is being used appropriately. Once your doctor
has provided this information, Gateway will make a
decision to authorize your drug for payment within
24 hours. You can use the drug formulary found on
the website to find your medication and see whether it
requires prior approval from Gateway. Drugs requiring
a prior authorization are marked with a “PA”.
What is Step Therapy?
If a drug must be approved by Gateway, step therapy
may require you to try a certain drug to treat your
medical condition before we will cover another drug.
For example, if Drug A and Drug B both treat your
medical condition, Gateway may not cover Drug B
unless you try Drug A first. If Drug A does not
work for you Gateway will then cover Drug B.
Drugs requiring step therapy are marked with
an “ST” on the online formulary.
Why are there Quantity Limits?
Some drugs on formulary have quantity limit restrictions.
Quantity limits are based on the Food and Drug
Administration’s (FDA) recommended dosing and are
put in place for your safety. Prescriptions in excess of
the covered monthly quantity will need to be requested
by your medical provider and will be reviewed by a
pharmacist and medical director at Gateway.
If you have any questions regarding medications that
require prior authorization, please call the Member
Services Department at 1-800-392-1147. TTY users
phone (711) or 1-800-654-5984. Also, you can now
use the Member Portal Online to:
• Search for Pharmacies
• Potential Drug-drug Interactions
• Drug Pricing
• View Pharmacy Claims
Steps to the Online Formulary
• Go to www.gatewayhealthplan.com.
• Select Members at the top of the home page.
• On the left side of the web page under “I am looking
to learn more about…” select Medical Assistance
(Medicaid).
• On the left side of the web page under “I am a
member looking to…” select Look Up a Medication.
• Select the first bulleted item Search Drug List
(Formulary).
• From the
formulary
page you
can search
by drug
name and
alphabetic
categories.
MARCH 2015
sPRING ALLERGIES AND ASTHMA
13
••• GATEWAY HEALTHSM
Your doctors have agreed to care for you in a timely manner. Please review the time frames below for each
appointment type:
DEFINITION
Emergency Care
A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses
an average knowledge of health and medicine,
could reasonably expect the absence of immediate
medical attention to result in:
a) placing the health of the individual (or, with
respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy,
b) serious impairment to bodily functions, or
c) serious dysfunction of any bodily organ or part.
Examples of emergency situations include
seizure,diabetic coma, cardiac arrest, obvious fracture.
PCPS & SPECIALISTS:
Immediately seen, or instructed to
call 911 or go directly to the nearest
emergency room.
A medical condition that may result in irreversible
complications or even death if injury or illness
is not treated in a timely manner. Any injury or
illness that has the potential to become something
more serious, or even deadly, is considered a basis
for receiving urgent care.
Examples of urgent care situations include abdominal
pain of unknown cause, unremitting new symptoms of
dizziness for unknown cause, suspected fracture.
PCPS & SPECIALISTS:
Seen within 24 hours.
Services provided to diagnose and treat conditions
to prevent deterioration to a more severe level, or
minimize/reduce risk of development of chronic
illness or the need for more complex treatment.
Examples include psoriasis, treatment of chronic conditions
such as chronic back pain.
SPECIALTY TYPE:
Dermatology, Dentist, Orthopedic
Surgery, Otolaryngology, and all
pediatric sub specialties:
Seen within 15 business days from
the date of referral.
Specialties not listed
above:
Seen within 10 business days from
the date of referral
PCPs:
Seen within 10 business days
Routine Care
General
Physical, Health
Assessment
or First Time
Examination
14
A complete health assessment which also includes
gathering information about a person’s medical
history and lifestyle, doing laboratory tests and
screening for disease.
Appointment standards below apply to Specialists and
PCPs who provide initial exams for special needs members.
EPSDT Screen
Within 45 days from the effective date of enrollment unless the
child is already under the care of a PCP and is current with screens
and immunizations.
Members known to be HIV positive
or diagnosed with AIDS
Within 7 days from effective date of enrollment, unless member is
already in active care with a PCP or specialist.
Members who receive supplemental
security income (SSI)
Within 45 days of enrollment unless the Member is already in
active care with a PCP or specialist.
Pregnant Members
Appointment standards below apply to OB/GYNs and PCPs
who provide prenatal care.
SCHEDULED APPOINTMENT
TIME FRAME
STANDARDS
Urgent Care
Special Needs Gateway
Medicaid Members
PCPS:
Within 3 weeks of enrollment in
the practice.
First trimester visit
Within 10 business days of the member being identified as
being pregnant .
Second trimester visit
Within 5 business days of the member being identified as
being pregnant.
Third trimester visit
Within 4 business days of the member being identified as
being pregnant.
High-risk pregnancy
Within twenty-four hours of identification of high-risk pregnancy.
Additional Office Standards for PCPs and Specialists
• No Show Policy – If a member misses an appointment, the practice is required to document the missed
appointment in the medical record. In addition,
three attempts must be made to contact the member.
At least one attempt must include a telephone call.
• Wait Time in the Waiting Room for Routine Care
The average office waiting time should exceed no
more than 30 minutes or at any time, no more
than up to one hour when the physician encounters
an unanticipated urgent medical condition visit
or is treating a member with a difficult medical
condition need.
• Wait time to speak with someone on the telephone
should be no longer than one minute.
After Hours Care for PCPs
• Primary Care Practices are responsible for providing
24 hour/7 days per week coverage for urgent or
emergent care.
• Gateway members must be instructed to call 911 or
go directly to the emergency room in the case of a
true emergency.
• Answering services or machines must instruct members on how to reach an on call physician.
MARCH 2015
GETTING THE CARE YOU NEED
15
The Doctor24-Hour Nurse
Patient
Line Now
Relationship:
Available
What’s Up Doc?
Gateway HealthSM wants our members to receive the
best possible care. One of the most important steps
you can take to make sure the care you are getting is
appropriate is to tell the providers you see about all
of your medical issues. Make sure your primary care
physician (PCP) knows if you are seeing other doctors
and the reasons for that care. This includes obstetricians
and gynecologists (OB/GYNs), family planning
providers, dentists, behavioral health providers such as
psychiatrists and psychologists, chiropractors and eye
doctors. Ask any specialists you see to inform your PCP
about any care or medicines provided for you. Please
agree to sign any forms that permit your doctors to
share information about your care with each other. You
can also talk to your PCP about information another
provider has given you about your care or any drugs a
provider has told you to take.
It is very important that all of your doctors know
about all medications you take, even over-the-counter
medicines, such as vitamins or herbal supplements.
Keep a written list of the medicines you take and carry it
in your purse or wallet so you can share this information
with your providers. Remember to update the list
when changes occur to make sure it includes all current
medicines and doses.
When should you be concerned about your child’s fever?
How can you tell the difference between a sprained ankle
and a broken one? Should you be applying ice or heat?
Wouldn’t it be nice to have a medical professional
available at any time to offer help with questions
like these? Now you can by picking up the phone and
calling the NurseWise nurse line toll-free at the phone
number provided below. All nurses are board certified
and licensed. The nurse line features bilingual staff and
language interpreters for nearly 200 languages.
With the nurse line, you can speak with a registered
nurse 24 hours a day, 7 days a week. Experienced
professionals are always available to offer expert answers
a to your questions. Simply explain your situation and
detail your symptoms, and our nurses will tell you
whether you should see your doctor, go to the emergency
room, or care for yourself at home.
It’s a simple call that could help save a life, or just
provide you much needed peace of mind. And best of all,
it’s a free service to all members. Why hesitate? The next
time you have any health-related questions, call the nurse
line at the phone number below. Also included with this
service is access to a pre-recorded audio library for just
about every health topic from A to Z.
NurseWise
phone number
Pennsylvania Medicaid
1-855-445-4244
2015
Healthchoices meetings
Gateway members are encouraged to attend
HealthChoices Consumer Advisory Meetings.
The meetings provide an opportunity to promote
the exchange of ideas between HealthChoices
consumers, providers and interested public and
private community organizations. The HealthChoices
program is sponsored by the Pennsylvania
Department of Human Services.
The 2015 regional HealthChoices
meeting times and locations:
South West Meetings – includes the following counties:
Allegheny, Armstrong, Beaver, Bedford, Blair, Butler,
Cambria, Fayette, Green, Indiana, Lawrence, Somerset,
Washington and Westmoreland counties.
Tuesday, April 7 • 10 a.m. – 12 p.m.
Location:
Somerset County Technology Center
Rooms A1-A2
281 Technology Dr.
Somerset, PA 15501
Lehigh/Capital Meetings – includes the following
counties: Adams, Berks, Cumberland, Dauphin,
Franklin, Fulton, Huntingdon, Lancaster, Lebanon,
Lehigh, Northampton, Perry and York counties.
Wednesday, April 22 • 10 a.m. – 12 p.m.
Location:
Hamilton Health Center
Community Room
110 South 17th St.
Harrisburg, PA 17104
New West Meetings – includes the following counties:
Cameron, Clarion, Clearfield, Crawford, Elk, Erie,
Forest, Jefferson, McKean, Mercer, Potter, Venango,
and Warren counties.
Wednesday, April 8 • 10 a.m. – 12 p.m.
Location:
Lock Haven University
Clearfield Campus, Academic Bldg.,
in multi-purpose Room A212
201 University Dr.
Clearfield, PA 16830
Please remember, the nurse line is for medical questions
only. If you need answers to questions about your health
care coverage, call the Member Services number on
the back of your member ID card. The nurse line phone
staff cannot assist you with issues regarding claims,
coverage or referrals.
16
MARCH 2015
TTY Users phone (711) or 1-800-654-5984
17
Four Gateway Center
444 Liberty Avenue, Suite 2100
TheinformationinthisnoticeisavailableinotherlanguagesandformatsbycallingGatewayHealthPlan®at1‐800‐392‐1147/Toll‐freeTTY711(1‐800‐654‐5984).
Pittsburgh, PA 15222-1222
LainformaciónenesteavisoestádisponibleenotrosidiomasyformatosllamandoaGatewayHealthPlan®al1‐800‐392‐1147/NúmerogratuitoTTY711(1‐800‐654‐5984).
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800‐654‐5984).
Данноеуведомлениеможнополучитьнадругихязыкахивдругихформатах,позвониввпланGatewayHealthPlan®пономеру1‐800‐392‐1147илипономеру711(1‐800‐654‐5984)
бесплатнойлинииTTY.
如需要本通知的其他语言和格式的版本，请致电 GatewayHealthPlan®：1‐800‐392‐1147/免费电话 TTY711(1‐800‐654‐5984)。
Moving?
If you are moving or changing your telephone number, please notify Member Services; TTY Users
B&támank~¬gesck¶ICUndMNwgenH KWmanCaPasa nigCaTMrg'ep§geTot edayTUrs&BæeTA Gateway Health Plan® tamelx²tecj«f 1-800-392-1147/TTY 711. (1-800-654-5984)
phone (711) or call 1-800-654-5984. For more information or paper copies of forms or other information,
call the area listed below to speak with our staff. More current information may be included on Gateway’s website,
www.GatewayHealthPlan.com, which is available 24/7. Information on Disease Management, Special Needs Areas,
and Member Rights and Responsibilities can also be accessed on our website as well.
TheinformationinthisnoticeisavailableinotherlanguagesandformatsbycallingGatewayHealthPlan®at1‐800‐392‐1147/Toll‐freeTTY711 (1‐800‐654‐5984).
LainformaciónenesteavisoestádisponibleenotrosidiomasyformatosllamandoaGatewayHealthPlan®al1‐800‐392‐1147/NúmerogratuitoTTY711(1‐800‐654‐5984).
Thôngtintrongthôngbáonàycóthể đượcdịchsangngônngữ kháchaycungcấpdướicáchìnhthứckháctheoyêucầu.XingọiGatewayHealthPlan®theosố 1‐800‐392‐1147/MiễnphíTTY711(1‐
800‐654‐5984).
Данноеуведомлениеможнополучитьнадругихязыкахивдругихформатах,позвониввпланGatewayHealthPlan®пономеру1‐800‐392‐1147илипономеру711(1‐800‐654‐5984)
бесплатнойлинииTTY.
如需要本通知的其他语言和格式的版本，请致电 GatewayHealthPlan®：1‐800‐392‐1147/免费电话 TTY711(1‐800‐654‐5984)。
B&támank~gesck¶ICUndMNwgenH KWmanCaPasa nigCaTMrg'ep§geTot edayTUrs&BæeTA Gateway Health Plan® tamelx²tecj«f 1-800-392-1147/TTY 711. (1-800-654-5984)
Important Phone Numbers
GATEWAY RESOURCES
Member Services
Pharmacy Member Services
Preventive Health
Outreach Staff
Community Development Dept.
Gateway To Lifestyle ManagementSM
MOM Matters® Program
Cardiac Program
Asthma Program
Diabetes Program
Spanish Speaking Members
Special Needs
Fraud and Abuse
OUTSIDE RESOURCES
Quitline (Stop Smoking) 1-800-QUIT-NOW
National Domestic Violence Hotline
ATT Operator for Deaf Members (PA Relay/TTY)
Center For Disease Control Nat’l AIDS Hotline
(ALL PHONE NUMBERS ARE TOLL-FREE)
Medicaid Numbers
1-800-392-1147
1-800-392-1147
1-800-642-3550, Option 4
1-800-642-3550, Option 4
412-255-7138
1-800-642-3550
Option 2
Option 3
Option 3
Option 3
Option 6
1-800-642-3550, Option 1
1-800-685-5235
1-800-784-8669
1-800-799-7233
711 TTY or 1-800-654-5984
1-800-232-4636
Gateway to Health is published as a service for the members of Gateway HealthSM. Information comes from a wide
range of medical experts and other medical resources. If you have concerns or questions about specific content,
please contact Gateway HealthSM.
Models may be used in photos and illustrations
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www.GatewayHealthPlan.com ©2015 Gateway HealthSM