Click below for more information on the following:
Access to Health Care Services
Continuity of Care
If your current healthcare provider is leaving the MemorialCare Select Health Plan network, you may be eligible for continuity of care if you have certain qualifying conditions. Please refer to the Continuity of Care Program policy and if you qualify, you may submit a completed application. Please download the Continuity of Care policy below.
Access to Health Care Services
The Provider Directory is a list of contracted MemorialCare Select Health Plan doctors. Doctors listed as Primary Care Providers (PCP) are responsible to help you coordinate your health care needs. PCPs are available within your general geographic area. MemorialCare Select Health Plan encourages you to choose a PCP.
There are times when your condition may require services and procedures not available in your PCP office. Your PCP may wish to order additional testing, treatment or evaluation by a Specialist. MemorialCare Select Health Plan ensures you have access to Specialist close to where you live.
Our contracted PCPs and Specialists will make sure you can get an appointment with your doctor in a timely manner.
MemorialCare Select Health Plan requires providers comply with the DMHC guidelines for appointment availability.
Our goal is for you to obtain health care services in a timely manner appropriate for your health care needs. If you cannot get a timely appointment in your area, we will help you locate a provider who can meet your health care needs.
You can call your PCP or Specialist 24-hours-a-day, 7 days a week to talk to a qualified health professional to decide if your health problem is urgent. If someone needs to call you back, they must call you within 30 minutes.
Click Here for MemorialCare Select Health Plan's Primary and Specialty Care Services Provider Directory.
Click Here to contact our Member Services if you need assistance in locating health care providers.
If you feel that you have a medical emergency, call 911 or go to the nearest Emergency Room.
Your Health Plan covers emergency care, even if you do not go to a Plan contracted hospital. Any Hospital Emergency Department must treat you until you are well enough to be moved to a contracted hospital or well enough to leave the Emergency Department. MemorialCare Select Health Plan maintains contracts with many well-known health plans in the communities we serve, and MemorialCare Select Health Plan is associated with Miller Children’s & Women's Hospital Long Beach and Long Beach Medical Center.
What Is an Emergency?
The law says that it is an emergency if you reasonably believe that it is an emergency. It is an emergency if waiting to get care could be dangerous to your life or a part of your body. A bad injury or a sudden serious illness can be an emergency. Severe pain and active labor are also emergencies. Your health plan must cover emergency care no matter where you are and what hospital you go to. However, you may be moved to a hospital in your health plan's network when you are stable enough to be moved.
What Is Urgent Care?
Urgent care is care you need within 24 to 48 hours. If you are within MemorialCare Select Health Plan's service area, you must use MemorialCare Select Health Plan doctors or urgent care centers. If you are more than 15 miles or 30 minutes away from your Primary Care Physician or Medical Group and require Urgent Care, get it right away. Needing Urgent Care is not an emergency. Urgent Care is care that is needed right away to relieve pain, find out what is wrong, or treat the health problem. We have 38 convenient locations to care for you. To find an Urgent Care facility near you, please view our brochure for a list of facilities in Los Angeles and Orange counties.
If you plan on traveling outside the United States, please call your Health Plan’s Member Services number on your I.D. card to determine your coverage.
You can call your Primary Care Physician, 24-hours-a-day, 7 days a week to talk to a qualified health professional to help you determine if your health problem is urgent. If someone needs to call you back, they must call you within 30 minutes.
If your health problem is urgent, your PCP will work with you to get an appointment as soon as possible but no later than 48 hours from your request. If your urgent health problem requires a specialist, your PCP and/or Specialist will work with you to get an appointment as soon as possible but no later than 96 hours from your request.
If you feel that you need health care services sooner than you can get an appointment, go to one of our contracted urgent care centers.
Your plan offers access to Mental Health, Behavioral Health Services, and Substance Use Disorder Treatment Services through Windstone Behavioral Health Inc. (a specialty Independent Practice Association). Treatment Services are coordinated and administered by Windstone. You do not need a referral from your PCP or from Windstone to see a Windstone Participating Provider for office visits for Mental Health, Behavioral Health Services, medication management or substance use disorder treatment. Certain Mental Health, Behavioral Health and Substance Use Disorder services require prior authorization from Windstone
For Mental Health, Behavioral Health and Substance Use Disorder Services, call your Windstone provider at (866) 388 -2810 TTY users call (714) 384-3337), unless it is an emergency.
Visit www.windstonehealth.com for more information on Winstone Behavioral Health Inc.
View a directory of Windstone Participating Provider:
Chiropractic and Acupuncture
Your plan offers access to chiropractic and acupuncture services through American Specialty Health (ASH). Treatment Services are coordinated and administered by ASH. American Specialty Health Incorporated and its subsidiaries are one of the nation’s premier independent and privately-owned specialty health services organizations, providing specialty health care networks and programs, fitness and exercise programs and population health solutions. Through its subsidiaries, ASH administers programs for nearly 34 million members and contracts with more than 32,000 health care practitioners and service providers. For specific benefits and coverage provided for these services, please refer to Evidence of Coverage and Disclosure under the Member Services page.
For chiropractic and acupuncture services, call ASH customer service toll free at (800) 678-9133 (TTY users call (877) 710-2746) or email them at firstname.lastname@example.org. Member Service Hours are as follows:
M-F: 4am - 8pm Pacific Time
Sat: 12pm - 8pm Pacific Time
Please visit ASH Participating Provider to search for a provider online.
MemorialCare Select Health Plan partners with MedImpact, the nation’s largest independent, privately owned pharmacy benefits manager, to offer members an extensive choice in pharmacies. Members may choose from hundreds of pharmacy locations including:
- Rite Aid
In need of a pharmacy? Please use the Pharmacy Locator in order to locate a pharmacy that is part of your network.
To use the Pharmacy Locator, at a minimum, please enter City and State or Zip, and select the distance you are willing to travel to a participating pharmacy. Pharmacy Locator will display participating pharmacies within the specified travel radius. You may also select to show only pharmacies that are open 24 hours a day or show only pharmacies that offer up to a 90-day supply of an ongoing medication.
MedImpact links patients, pharmacists and physicians together, helping ensure the appropriate use of medication for each individual based upon their personal medication profile, pharmacy benefit coverage, and best clinical practices. MedImpact products, programs and services are designed to help control total health care costs, improve quality of care and increase member satisfaction. For questions, please contact MedImpact Customer Service at (844) 513-6001 or email@example.com for additional assistance.
Non-Formulary Prescription Drug Exception Requests
If we deny a request for coverage of a non-formulary drug, you, your authorized representative or your doctor may request that the original exception request and subsequent denial of such request be reviewed by an Independent Review Organization (IRO). You, your authorized representative or your doctor may submit a request for IRO review up to 180 calendar days following the non-formulary drug exception request denial by:
- Calling 1-844-805-8700
- Mailing a written request to:
- Completing the member grievance form online at mshp.org.
You will be notified of the IRO’s decision within 72 hours for standard requests or 24 hours for expedited requests. The IRO review process described above is in addition to your rights to file a grievance with MemorialCare Select Health Plan or request an Independent Medical Review (IMR) with the Department of Managed Health Care (DMHC).
Prescription Drug List
MemorialCare Select Health Plan's drug formulary is a listing of all brand name and generic medications that have been approved by the FDA that are preferred by MemorialCare Select Health Plan. MemorialCare Select Health Plan contracts with MedImpact Health Systems, a Pharmacy Benefit Manager (PBM) to provide access to a nationwide network of participating pharmacies, mail order prescription drug services, claims payments for prescription drugs and management of the Plan’s drug formulary list. Your PCP will prescribe medications from the drug formulary list, as they have been reviewed thoroughly to ensure safety, effectiveness and the highest quality of care.
For your convenience, MemorialCare Select Health Plan offers a Mail Order option so your medication can be delivered to your home through Postal Prescription Services.
To order prescriptions by mail, please download and submit the Mail Order Form below.
To order by phone, please call 1 (800) 552-6694
Submit a Pharmacy Claim
If you choose to fill your prescription at a non-Participating Pharmacy, your costs may increase. You will likely need to pay for the entire amount of the prescription and then submit a prescription drug claim form for reimbursement to us.
Members that submit claims from non-Participating Pharmacies are reimbursed based on the lesser of the billed charge or on a prescription drug maximum allowed amount. The prescription drug maximum allowed amount may be considerably less than you paid for your medication. You are responsible for paying any difference in cost between the prescription drug maximum allowed amount and what you paid for your medication.
To submit a pharmacy claim, please download and fill out the Pharmacy Claim Form below.
To submit a pharmacy compound claim, please download and fill out the Pharmacy Compound Claim Form below.
Price A Drug
Wondering how much your prescriptions will cost? Please refer to the Drug Price Check to determine your cost for prescriptions. For a full list of medications covered, please refer to the Prescription Drug List above.
MemorialCare Select Health Plan offers specialty pharmacy through US Bioservices. US Bioservices has provided specialty medications and services that improve patients’ lives for nearly 20 years. US Bioservices understands the issues patients face and are committed to supporting them throughout their therapy by providing compassionate care and in-depth knowledge. For more information about US Bioservices, please refer to the Specialty Pharmacy Brochure below:
To initiate or transfer your prescription, contact US Bioservices toll free at 1 (888) 518-7246 or ask your physician to call.
Specialty medications are usually dispensed as an injectable drug but may be available in other forms, such as a pill or inhalant. They are used to treat complex conditions. Prescriptions for specified specialty pharmacy drugs are covered only when ordered through the specialty pharmacy program unless you are given an exception from the specialty drug program. The specialty pharmacy program will deliver your medication to you by mail or common carrier (you cannot pick up your medication). You may have to pay the full cost of a specialty pharmacy drug if it is not obtained from the specialty pharmacy program. Specialty drugs that must be obtained through the specialty pharmacy program are limited to a 30 day supply for each fill.
Referrals to Specialists
To see a Specialist or another provider, you usually need a referral from your Primary Care Physician and prior authorization from either your Medical Group or MCSHP. If you do not get the required referral and prior authorization and you get the service or treatment, you will have to pay all of the cost. For a list of services that do not require referrals, please refer to the Evidence of Coverage and Disclosure section on the Member Services page.
If you have certain life-threatening, degenerative or disabling condition or disease requiring specialized medical care over a prolonged period of time, including HIV or AIDS, you may be provided with a standing referral. A standing referral is a referral for more than one visit, to a Specialist or “specialty care center” that has demonstrated expertise in treating a medical condition or disease involving a complicated treatment regimen that requires on-going monitoring. Those Specialists designated as having expertise in treating HIV or AIDS are designated in our Provider Directory under their licensed specialty with an asterisk.
Certain health care services require Prior Authorization by your Medical Group or MemorialCare Select Health Plan (MCSHP) in order to be covered. For additional information regarding services that require prior authorization or to obtain a copy of the clinical review criteria, at no cost, and any training material or resources used by MemorialCare Select Health Plan, please call 1 (844) 805-8700.
Your Primary Care Physician must contact MCSHP or in some cases, the participating Medical Group with which your Primary Care Physician is affiliated, to request the service or supply be approved for coverage before it is rendered. Certain Mental Health, Behavioral Health or Substance Use Disorder Treatment Services require Prior Authorization by Windstone in order to be covered. For Mental Health, Behavioral Health or Substance Use Disorder Treatment Services, the Windstone Participating Provider must contact Windstone for Prior Authorization. If Prior Authorization is not obtained when required, you may be liable for the payment of services or supplies. Requests for Prior Authorization will be denied if the requested services are not Medically Necessary as determined by MCSHP or the Medical Group or Windstone, as applicable.
Authorization, Modification and Denial of Health Care Services
MemorialCare Select Health Plan (MCSHP) uses established Utilization Mangement (UM) criteria to approve, deny, delay or modify authorization of benefits based on medical necessity. The criteria used for evaluating requested health care services are based on generally accepted and professionally recognized standards of medical practice. For medical health care services, MCSHP and its contracted Medical Groups utilize the UM criteria application hierarchy as follows:
- Federal or State Mandate;
- Health Plan Medical Policy or Clinical Guideline;
- Standardized Criteria (Milliman or InterQual);
- Provider Group Criteria or Guideline;
- Community Resources (peer reviewed journals or published resources);
- If none apply, professional judgment is used.
Authorization, Modification and Denial of Mental Health and Substance Use Disorders (MH/SUD)
MemorialCare Select Health Plan utilizes criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty to approve, deny, delay or modify authorization of MH/SUD benefits based on medical necessity as follows:
- Substance use disorder any age – ASAM 3rd Edition 2013;
- Mental Health Disorders Patients 18 and Older – Level of Care Utilization System (LOCUS) 20 2020;
- Mental Health Disorders Patients 6 to 17 years of age – Child and Adolescent Level of Care Utilization System (CALOCUS) 20 or Child and Adolescent Service Intensity Instrument (CASII) 2019;
- Mental Health Disorders Patients 0 -5 years of age – Early Childhood Service Intensity Instrument (ESCII); and
- General Dysphoria – WPATH Standards of Care Version 7 2012