Member NEWSLETTER
FALL ISSUE • SEPTEMBER 2026
Featured this issue EXPLORE YOUR VCHCP WEBSITE.............................. DECODE YOUR BENEFITS CROSSWORD - GAME #2 ............................................
8
10 AUTHORIZATIONS & REFERRALS .................... 12
Fall 2026 Members Newsletter Online Flipbook You can view and access links with your phone or computer. Scan this QR Code or go online to: tinyurl.com/vchcpFall2026
Contents
Patient Emergency & Provider After Hours.............................................................. 3
FALL ISSUE • SEPTEMBER 2026
Empowering You in Low Back Pain Care: Choosing the Right Approach........................... 31
How Teamwork Can Help You............................. 4
Child Immunizations........................................... 31
VCHCP Member Behavioral Health and Substance Use Resources............................. 4
Omada Hypertension Program......................... 31
VCHCP Member Portal.......................................... 5
CONTACT INFORMATION
Ventura County Health Care Plan
Seven Tips to Stay on Track.................................. 6
Regular Business Hours are:
Notice To Members Regarding Behavioral Health & Wellness Screening For Children......................................... 9
• vchcp.venturacounty.gov • VCHCP.Memberservices@venturacounty.gov • Phone: (805) 981-5050 • Toll-free: (800) 600-8247 • FAX: (805) 981-5051 • Language Line Services: Phone: (805) 981-5050 Toll-free: (800) 600-8247 • TDD to Voice: (800) 735-2929
Explore Your VCHCP Website.............................. 8
Nondiscrimination................................................. 9 How to Find a Provider......................................... 9
Regular Business Hours are:
Taking the Right Steps for Upper Respiratory Infections............................34 Flu Vaccine.............................................................35 Throat Infections: Choosing Wisely for Your Health......................35
Member Satisfaction with Utilization Management....................................38
What Makes Our Provider Network Exceptional?......................................... 12
Have Your Say About Your Experience ...........39
Authorizations & Referrals ................................ 12 Submitting an External Exception Review Request................................. 13 Case Management & Disease Management Services......................... 14 Coordinating Your Care...................................... 14 Accessing Services for Behavioral Health................................................ 15 Case Management...............................................16
Understanding Your Pharmacy Benefits.....................................18
VCHCP Utilization Management Staff
Combating Respiratory Infections: The Power of Antibiotic Awareness.................34
2026 HEDIS Results from Measurement Year 2025 and Interventions............................. 11
• 24/7 Pharmacy/Express Scripts: (800) 811-0293 express-scripts.com
• 24/7 Teladoc: (800) 835-2362
Frequently Asked Questions About Specialty Medications............................33
Everyone Deserves to Have a Healthy, Smokefree Home.................................................36
TAR Process........................................................... 17
• 24/7 Nurse Advice Line: (800) 334-9023
Flu Facts.................................................................32
Decode Your Benefits Crossword.....................10
• Voice to TDD: (800) 735-2922
• 24/7 Behavioral Health/Optum: (800) 851-7407 liveandworkwell.com
Referral & Prior Authorization Process and Services Requiring Prior Authorization .........18
Optum Calm Health App.................................... 19 What is Optum’s Complex Case Management Program?............................20 A Message From our Case Management Nurse ..................................22 How Often Should You See Your Primary Care Provider?.............................22 New Medical Technology...................................23 Get your OneTouch meter..................................23
Express Scripts......................................................39 Standing Referrals...............................................39 2026 National Preferred Formulary Exclusions..........................................39 Why Metabolic Testing Matters........................40 Follow-Up Care for Children and Teens After Starting ADHD Medicine.............. 41 Psychosocial Care for Children and Teens........................................42 Wellness Programs..............................................43 Formulary Web Posting & Pharmacy Updates..............................................44 How to request a Step Therapy Exception, Formulary Exception and Prior Authorization Exception..........................45 Population Health Management Programs......................................45 Emergency Room vs Urgent Care.....................46 Anti-Depressant Medication Management...................................47 Depression Education Materials Available..............................................47 The Importance of Well Child Visits.................48
Wellness Wire: Diabetes and Heart Health.....24
What is MDD? Far More Than Just Feeling Sad....................................................49
Milliman Care Guidelines & Medical Policy Updates ..................................25
OptumHealth Behavioral Solutions ................50
2026 Quality Improvement Program Evaluation.............................................25
Autism Spectrum Disorders..............................51
Autism Screening For All Children...................51
Clinical Practice Guidelines...............................25
Doulas.....................................................................52
Monday - Friday, 8:30 a.m. to 4:30 p.m.
Breast Cancer Screening....................................26
Prenatal Care in your First Trimester...............53
Colorectal Cancer Screening.............................27
Preventive Health Guidelines...........................54
Diabetic Retinal Exam.........................................28
• (805) 981-5060
Education Materials.............................................28
VCHCP Maternal Mental Health Program and Maternal and Infant Health Program......54
Graphic Design & printing
Request Complex Case Management, Case Management or Disease Management.........................................................29
Gender Inclusive, Sensitive Language is Important.......................................58
Post Inpatient Discharge Follow-Up................30
Gender Affirming Procedures and Services...58
OptumHealth Quality Program........................30
VCHCP Network Updates...................................58
Direct Specialty Referrals...................................29
GSA Business Support/Creative Services 2
Timely Access Requirements............................... 3
Language and Communication Assistance................................................................ 5
Monday - Friday, 8:30 a.m. to 4:30 p.m.
Adult Preventive Care.........................................30
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
10 Tips to Quit.......................................................55 Mental Health Emergency? Call 988................56
Patient Emergency & Provider AFTER HOURS CONTACT
A GREAT RESOURCE in Ventura County...
THE NURSE ADVICE LINE
Ventura County Medical Center Emergency Room 300 Hillmont Avenue, Ventura, CA 93003 (805) 652-6165 or
(805) 652-6000
Santa Paula Hospital
A Campus of Ventura County Medical Center 825 N Tenth Street Santa Paula, CA 93060 (805) 933-8632 or
(805) 933-8600
Ventura County Health Care Plan
on call Administrator available 24 hours per day for Emergency Providers (805) 981-5050 or
(800) 600-8247
1-800-334-9023
Available 24 hours a day, 7 days a week for Member questions regarding their medical status, about the health plan processes, or just general medical information. THERE IS ALSO A LINK ON THE MEMBER WEBSITE: vchcp.venturacounty.gov/nurse-advice-line that will take Members to a secured email where they may send an email directly to the advice line. The nurse advice line will respond within 24 hours. To speak with VCHCP UM Staff, please call the Ventura County Health Care Plan at the numbers below: QUESTIONS? CONTACT US: MONDAY - FRIDAY, 8:30 a.m. to 4:30 p.m.
Phone: (805) 981-5060 or toll-free (800) 600-8247 FAX: (805) 981-5051, vchcp.venturacounty.gov TDD to Voice: (800) 735-2929 Voice to TDD: (800) 735-2922 Ventura County Health Care Plan 24-hour Administrator access for emergency providers: (805) 981-5050 or (800) 600-8247 Language Assistance - Language Line Services: Phone (805) 981-5050 or toll-free (800) 600-8247
2 •1•1 can assist patients with counseling, food assistance, domestic violence services, employment resources, health care, senior services, legal assistance, substance abuse services, housing, resources for parents, and much more! 2 •1•1 is available 24 hours a day, 7 days per week. You can also visit 211ventura.org.
TIMELY ACCESS REQUIREMENTS VCHCP adheres to patient care access and availability standards as required by the Department of Managed Health Care (DMHC). The DMHC implemented these standards to ensure that members can get an appointment for care on a timely basis, can reach a provider over the phone and can access interpreter services, if needed. Contracted providers are expected to comply with these appointments, telephone access, practitioner availability and linguistic service standards. If a timely appointment is not available at any of our contracted clinics/facilities, then an out-of-network (OON) referral request should be sent by the referring provider to the Plan for authorization. The authorization request must include the details regarding the access issue and why an OON referral is required. NOTE: The referring provider may allow for an appointment outside of the timely access requirements if it will not be harmful to the patient’s health. These instances must be documented in the patient’s chart and communicated to the patient.
Type of Care
Wait Time or Availability
Emergency Services
Immediately, 24 hours a day, 7 days a week
Urgent Need – No Prior Authorization Required Urgent Need – Requires Prior Authorization Primary Care Specialty Care Ancillary services for diagnosis or treatment
Within 48 hours Within 96 hours Within 10 business days Within 15 business days Within 15 business days
Mental Health and Substance Use Disorder including nonurgent follow-up appointments with nonphysician mental health care or substance use disorder providers
Within 10 business days
Phone wait time for triage or screening by the provider office
Not to exceed 30 minutes
Wait time for enrollees to speak with a qualified Plan representative during business hours
Not to exceed 10 minutes
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
3
How
TEAMWORK Can Help You Your brain is part of the rest of your body. If you are seeing a mental health specialist and your mental health specialist and medical doctor (Primary Care Physician or PCP) talk, you get better treatment. The way to make this possible is to sign a Confidential Exchange of Information Form and Authorization for Release of Information Form for each one of your providers. If you are seeing a mental health specialist, inform them how to contact your PCP and other healthcare providers. Your PCP will also want to know that you are seeing a mental health specialist.
Some reasons why working together is important: •
You may be getting medicines from your psychiatrist as well as your PCP.
•
Some medicines do not work well together.
• Your doctors need to know all the medicines, including non-prescription medicines you are taking. • Medical problems can cause mental health problems. •
Mental health problems can cause medical problems.
You can find the OptumHealth Behavioral Solutions of California Confidential Exchange of Information Form and Release of Information Form on liveandworkwell.com and also available at vchcp.venturacounty.gov/resources-and-forms. The information your healthcare providers share is private to the fullest extent permitted by law. Your PCP may decide to use their own Release of Information form. If so, make sure it includes the ability to exchange mental health information. List the names of all your healthcare providers. Share this list with each person you listed and ask them to work together. If you are seeing a PCP, be sure that your PCP is collaborating care with any of your other treating providers including a mental health specialist. Communication is the key for your overall health care.
VCHCP Member Behavioral Health and Substance Use RESOURCES Member Website and Provider Directory: LiveandWorkWell.com Optum Intake and Care Management For Intake and Referrals: (800) 851-7407 Optum covers all Substance-Use-Disorder services identified in the American Society of Addictions Medicine (ASAM) criteria, and as of January 1, 2021, this includes ASAM levels 3.1 and 3.2 WM services.
4
Member Newsletter
Substance Use Disorder Helpline: 1-855-780-5955 A 24/7 helpline for VCHCP Providers and Patients
If you have paid for these services out of pocket, you can submit claims for retrospective review to the following address:
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Optum Claims Processing P.O. Box 30755 Salt Lake City, UT 84130-0755
VCHCP Member Portal As a VCHCP Member, you can access your personal Health Plan information online by creating a profile through the VCHCP Member Login link found on the Plan’s website: vchcp.venturacounty.gov Once you are logged in you will be able to access personalized information about your: • Benefits • Claims Status • Authorizations Status
You will also be able to: • • • •
Request ID Cards Print your ID Cards Submit Reimbursement Forms Submit a General Plan or Coverage Question
To register for the portal…
- Go to vchcp.venturacounty.gov - Click on “For Members” - Click on “VCHCP Member Portal”
Create Your Own VCHCP Member Online Profile
For questions on accessing the portal, please contact Member Services at (805) 981-5050 or (800) 600-8247, Monday – Friday 8:30 a.m. – 4:30 p.m., or email VCHCP.Memberservices@venturacounty.gov
Language and Communication Assistance Good communication with VCHCP and with your providers is important. If English is not your first language, VCHCP provides interpretation services and translations of certain written materials. • To ask for language services call VCHCP at (805) 981-5050 or (800) 600-8247. You may obtain language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner. You may obtain interpretation services free of charge in English and the top 15 languages spoken by limited-English proficient individuals in California as determined by the State of California Department of Health Services. • If you are deaf, hard of hearing or have a speech impairment, you may also receive language assistance services by calling TDD/TTY at (800) 735-2929.
• If you have a preferred language, please notify us of your personal language needs by calling VCHCP at (805) 981-5050 or (800) 600-8247. • Interpreter services will be provided to you, if requested and arranged in advance, at all medical appointments. If you have a disability and need free auxiliary aids and services, including qualified interpreters for disabilities and information in alternate formats, including written information in other formats, you may request that they be provided to you free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity for you to participate.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
5
Seven Tips to Stay on Track with Your Diabetes Management During the Holidays The holidays are a time to eat, drink, and be merry! However, eating and drinking sugary foods and drinks can make it challenging to manage weight and blood glucose (blood sugar)—which might not leave you feeling merry. Here are seven tips you’ll need to survive this holiday season and stay on track with your diabetes management.
01 Prioritize Self Care If you are hosting a holiday party, you likely have a big to-do list. This may include grocery shopping, baking, cooking, cleaning, decorating, setting the table, and other hosting duties. To avoid feeling overwhelmed, take care of yourself in the days leading up to the holiday party by keeping your blood glucose managed well, eating your meals on time, maintaining a consistent sleep schedule, and setting a reminder to take any medications.
6
Member Newsletter
02 Bring a Healthy Dish to Share If you are attending as a guest, you may have been assigned to bring an appetizer, side dish, entrée, or dessert. Instead of bringing a holiday staple (which tends to have sugary ingredients), this is your chance to bring something healthier to the table! A healthier version of traditional dishes will not only be great for you but for your family as well. To cut back on carbs and added sugar, try swapping out a traditional dish made with sugar for one made with a low-calorie or low-carb substitute.
03 Avoid Skipping Meals Some people may skip breakfast and lunch the day of a holiday to “save room” for the big holiday dinner. But for people with diabetes, this can have consequences. First, it can lead to blood glucose dips, especially if taking certain diabetes medications like insulin or a sulfonylurea. Second, it can lead to overeating at dinner, which can cause your blood glucose to spike. You don’t necessarily need to eat a BIG breakfast or lunch the day of a holiday, but these meals should at least be balanced and well-spaced.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
4: Practice Mindful Eating Over Mindless Eating Lingering around the food table can lead to mindless eating — eating when distracted, not hungry, or not being fully aware of what or how much you are eating. Unsurprisingly, the opposite of mindless eating is mindful eating. Mindful eating is being intentional about what you are taking from the food table. You are fully aware of the food—how it tastes and smells, its texture, and how it makes you feel. You are eating in response to hunger cues.
5 Plan Out Your Plate Regardless of whether the food is served from the kitchen (buffet-style) or from the table (family-style), you should scope out all your options before plating your food. Otherwise, you may end up with a heaping plate of starchy sides and very little protein and vegetables. Be selective. Of course, include your favorites, but ensure that you still watch your portion sizes. You can use the Diabetes Plate for guidance!
6 Think About Your Drink Drinks can be a major source of “hidden” calories and added sugars. That’s because they don’t feel as filling as food, so you may not realize how many calories and added sugars you’re consuming. For example, a regular 12-ounce cola contains around 140 calories and 40 grams of added sugars! That is more added sugar than a person should have in an entire day! Major sources of added sugars are sugary beverages. The American Heart Association recommends limiting added sugars to no more than 25 grams per day for most women and 36 grams per day for most men.* Instead of sweetening your holiday tea or coffee with sugar, use a low-calorie or low-carb substitute. And if you like cream in your coffee, look for ones that are unsweetened and low-carb. If you enjoy drinking water with your meal but want some flavor, get creative with fruit and herb combinations like blackberry and mint, watermelon and basil, or lavender and lemon.
7 Move After the Meal The last thing you should do after a big holiday meal is lay on the couch for long periods of time as this can lead to high blood glucose. Try to get up and move! Go for a walk with your pet, a family member or friend after the meal. Play with your children or grandchildren. Or play a game of flag football in the yard — the options are endless! Moving after a meal can help keep blood glucose levels stable and manageable. Just make sure to test your blood glucose before and after physical activity or as directed by your health care professional. Physical activity can affect people with diabetes’s blood glucose in different ways, so it’s always best to check in with your health care professional!
*American Heart Association. (2021). Added Sugars. heart.org/en/healthy-living/ healthy-eating/eat-smart/sugar/added-sugars Sources: American Diabetes Association. Nutrition for life: sugar substitutes. professional. diabetes.org/sites/dpro/files/2023-12/sugar_substitutes.pdf American Diabetes Association. 7 tips to stay on track with your diabetes management during the holidays. diabetes.org/health-wellness/weightmanagement/stay-pn-track-during-holidays American Diabetes Association. (2025). Best beverages for people with diabetes. diabetesfoodhub.org/blog/best-beverages-people-diabetes
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
7
Visit vchcp.venturacounty.gov to learn more!
View and download important plan documents and benefit information. Access your Summary of Benefits and Coverage (SBC) Evidence of Coverage (EOC), member handbook, health plan overviews, benefit guides, and more— whenever you need them.
Prefer to speak with someone? Call our Member Services Department at (805) 981-5050 for assistance.
ADDITIONAL RESOURCES Available 24/7
Behavioral Health (Optum)
Language Assistance Program
Find a Pharmacy (Express Scripts) Nurse Advice Line Teladoc 8
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
NOTICE TO MEMBERS Regarding Behavioral
Health & Wellness Screening For Children Subject: AB 2556 – Behavioral Health & Wellness Screening for Children Ages 8-18
• What is included? A behavioral health and wellness screening, which helps assess emotional well-being, stress, anxiety, depression, and other mental health concerns.
Recent California legislation, Assembly Bill (AB) 2556, requires VCHCP to inform members about the benefits of behavioral health and wellness screenings for children and adolescents ages 8 to 18. These screenings play a crucial role in identifying and addressing mental health concerns early, supporting overall well-being and development.
• Why is it important? Early detection and intervention can improve long-term mental and physical health outcomes.
What You Need to Know: • Who is eligible? Children and adolescents between the ages of 8 and 18.
• How can you access this benefit? You may access services through Optum by calling (800) 851-7407, or by visiting Optum’s website at liveandworkwell.com. We encourage you to take advantage of this important benefit to support your child’s health and well-being. If you have any questions, please contact Member Services at (805) 981-5050.
Nondiscrimination VCHCP complies with applicable Federal and California laws and does not exclude people or otherwise discriminate against them because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) enforces certain Federal civil rights laws that protect the rights of all persons in the United States to receive health and human services without discrimination based on race, color, national origin, disability, age, and in some cases, sex and religion. If you have any questions, or need help to file your complaint, call OCR (toll-free) at (800)-368-1019 (voice) or (800-537-7697) (TDD), or visit their website at: hhs.gov/ocr. You may also send an email to OCRcomplaint@hhs.gov.
How to Find a Provider The online Provider Directory is updated weekly thus providing the most accurate information available. To access the directory please visit our website at vchcp.venturacounty.gov/ProviderSearch.php. For a printed copy of the directory contact Member Services at (805) 981-5050 or (800) 600-8247 or via email at VCHCP.Memberservices@venturacounty.gov.
If you believe that you have been discriminated against you may file a complaint with the Office for Civil Rights (OCR). You can file your complaint by email at OCRcomplaint@hhs.gov, or you can mail your complaint to: Centralized Case Management Operations U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F HHH Bldg. Washington, D.C. 20201
Select your plan: Select a provider type: Select a specialty: Select a city: Select a language: Select a gender: Select Name of Clinic... Select Name of Hospital...
TIP: When searching for a specialist, make sure to select a specialty but ensure that the provider type is set at “All Provider Types” as selecting a provider type will limit the options available.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
9
1 2
3
4
6
8
9
when it is
10
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
5
7
2026 HEDIS
RESULTS FROM MEASUREMENT YEAR 2025 AND INTERVENTIONS
We are delighted to share the exceptional results of Ventura County Health Care Plan (VCHCP) in the 2026 HEDIS measures, based on data from Measurement Year 2025. Our dedication to excellence is evident in various key areas, including preventive screenings for breast cancer, colorectal cancer, and cervical cancer, as well as appropriate childhood immunizations. By meeting these measures, we work together to reduce disease and complications, ensuring better health outcomes for all our members.
Celebrating 2025 Accomplishments The past year saw remarkable improvements in several areas, such as cervical cancer screening, colorectal cancer screening, chlamydia screening, hbA1c testing for diabetics, antidepressant medication management, and child and adolescent well-care visits. Our Diabetes Disease Management Program has played a pivotal role in providing personalized health coaching calls to members with moderate to high risk. By working together, we have seen significant improvements in compliance with HgbA1c testing and risk reduction.
Setting Our Sights on 2026 Goals
As we look to the future, VCHCP is committed to enhancing our healthcare services further. In 2026, we aim to focus on the following crucial areas: 1. Breast Cancer Screening: Encouraging all women aged 40-74 to receive a screening mammogram every two years.
Working Together for Improvement Our journey to success would not be possible without the active participation of our members. To achieve our goals in 2026, we continue to implement a range of interventions, including personalized outreach for preventive health screenings, postcard reminders for breast cancer screenings, health coaching calls and mailed resources for diabetics, follow-up care letters for new moms, birthday cards with care gap information, phone outreach regarding the use of doula services for eligible members, reminder follow-up calls for child and adolescent immunizations, identified members screened positive for depression screening are referred to Optum CM for follow-up and CM phone outreach to identified members to get their annual diabetic screening due to risk of diabetes when taking antipsychotics.
Partnering for a Healthier Future
3. Postpartum Care: Supporting new moms with postpartum visits within 7-84 days of delivery.
At VCHCP, we believe that your health journey is a partnership between you, your Primary Care Physician, and our dedicated HEDIS team. By fulfilling these important HEDIS measures, you are taking charge of your health and contributing to a stronger and healthier community.
5. Comprehensive Diabetes Care: Continuously improving diabetes care for better health management.
If you have any questions about the services you may need, we encourage you to reach out to your primary care physician. For questions related to HEDIS, please contact VCHCP at (805) 981 5060.
2. Colorectal Cancer Screening: Ensuring all adults aged 45-75 receive timely screenings based on recommended intervals.
4. Controlling High Blood Pressure: Assisting members diagnosed with hypertension to maintain blood pressure levels below 140/90.
6. Childhood Immunization: Encouraging completion of childhood vaccinations by age 2.
Together, let’s continue striving for excellence and building a healthier future for all.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
11
What Makes Our Provider Network Exceptional? At VCHCP, we know your health and well-being depend on access to trusted, high-quality care. That’s why we’ve built one of the strongest provider networks in Ventura County; designed to give you peace of mind, convenient access, and exceptional care.
✅ Top-Quality Providers
Our network includes hundreds of board-certified doctors, specialists, and leading hospitals. From preventive care to complex treatments, you’re connected to professionals known for their experience, compassion, and results.
✅ Convenient Access, Close to Home
With providers located in communities across the county, it’s easier than ever to get the care you need, when and where you need it. In addition to the 200+ VCMC providers in our network, we also have an additional 300+ privately contracted providers throughout Ventura County. In East County, we have 60+ providers and are continuing to focus our contracting efforts in that area.
✅ Specialist Access Without the Runaround
Need to see a specialist? In most cases, your Primary Care Physician can directly refer you to a network specialist, without the need to get approval from VCHCP. That means faster access to the care you need without unnecessary delays.
Find a Provider Today Explore our provider directory at vchcp.venturacounty.gov/ProviderSearch.php to search by name, specialty, or location. Prefer to speak with someone? Call our Member Services Department at (805) 981-5050 for assistance. Your health plan is more than just coverage—it’s a connection to care you can trust. With our extensive provider network, you’re never far from the support you need to stay healthy and thrive.
Authorizations & Referrals VCHCP wants to ensure that you can obtain the services needed and recommended by your doctor, by eliminating barriers. That is why we continue to review services that require prior authorization and when appropriate, remove the prior authorization requirement or move the services to the direct referral list. DIRECT REFERRALS Those services on the Direct Referral List do not require prior authorization from VCHCP. This means that your PCP can provide you with a referral to a contracted specialist, without the need to wait for an authorization from the Plan. The current Direct Referral Chart is available on the VCHCP website: vchcp.venturacounty.gov/Authorizations-and-Referrals
AUTHORIZATIONS For those services that do require prior authorization, VCHCP has stringent guidelines regarding turnaround time. Once VCHCP receives the authorization request from the provider, a decision will be made within 5 business days for standard requests, and within 72 hours for urgent requests. Although VCHCP cannot control when the office submits the authorization request, once received we ensure that the above noted timelines are met. 12
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
H ow To
SUBMITTING AN EXTERNAL EXCEPTION REVIEW REQUEST
for the denial of Request for Step Therapy Exception, Formulary Exception, and Prior Authorization for a Medication
You, your designee, or your prescribing doctor can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization by following the steps below:
• Submit an exception via online request available in the VCHCP member website by clicking vchcp.venturacounty.gov/request-forpharmacy-formulary-exception or by calling the Plan at (805) 981-5050.
• Ask the Plan to make an exception to its coverage rules.
• There are several types of exceptions that can be requested such as:
- Cover a drug even if it is not on the Plan’s formulary. - Waive coverage restrictions or limits on a drug.
For example, the Plan limits the amount on certain drugs it covers. If the drug has a quantity limit, ask the Plan to waive the limit and cover more.
- Provide a higher level of coverage for a drug. For
example, if the drug is in the Non-Preferred Drug tier, ask the Plan to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Drug tier 3 instead. This applies so long as there is a formulary drug that treats your condition on the Preferred Brand Drug tier 3. This would lower the amount paid for medications.
• Once the Plan receives the exception request via
website or via phone call, the Plan’s Utilization Management will contact your doctor to process your External Exception Review Request.
•
The Plan sends your external exception review request to an independent review organization called IMEDECS/Kepro.
• VCHCP will ensure a decision and notification
within 72 hours in routine/standard circumstances or 24 hours in exigent circumstances.
• The Plan will make its determination on the external exception request review and notify the member or the member’s designee and the prescribing provider of its coverage determination within 24 hours following receipt of the request, if the original request was an expedited formulary/ prior authorization/step therapy exception request or within 72 hours following receipt of the request, if the original request was a standard request for nonformulary prescription drugs/step therapy/prior authorization.
• If additional information is required to make a decision, the Plan in collaboration with IMEDECS/Kepro will send a letter via fax to your prescribing doctor advising that additional information is required.
• Exception requests for step therapy/nonformulary/ prior authorization will be reviewed against the criteria in Section 1367.206(b) and, if the request is denied, the Plan will explain why the exception requests for step therapy/nonformulary/prior authorization drug did not meet any of the enumerated criteria in section 1367.206(b).
• The exception request review process does not affect or limit the member’s eligibility for independent medical review or to file an internal appeal with VCHCP.
• The member or member’s designee or guardian
may appeal a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request by filing a grievance under Section 1368.
• If the independent review organization
reverses the denial of a prior authorization, formulary exception, or step therapy request, the decision is binding on the Plan.
• The decision of the independent review organization to reverse a denial of a prior authorization, formulary exception, or step therapy request applies to the duration of the prescription, including refills.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
13
CASE MANAGEMENT & VCHCP has a Case Management Program to help
our members who have complex needs by ensuring that our members work closely with their doctors to plan their care. Case Management is a collaborative process of assessment, planning, facilitation, and advocacy. Determination is made for the best options and services to meet a member’s individual health needs through communication and utilization of available resources to promote quality care and costeffective clinical outcomes. The goals of Case Management are to help members get to their best health possible in the right setting; coordinate and manage healthcare resources; support the treatment plan ordered by the doctor; and to take action to improve member overall quality of life and health outcomes. As a member in Case Management, members with complicated health care issues and their
family have a truly coordinated plan of care. VCHCP identifies members for Case Management through several referral sources, including health care provider referrals and member self-referrals.
Your Healthcare plan for the future starts here!
Members appropriate for case management referral include those members with medical and psychosocial needs impacting their compliance with disease management and health improvement including increasing severity of condition, safety issues, decreasing functional status, new behavioral health issues, need for caregiver resources. Some examples of eligible medical conditions or events include multiple hospital admissions or re-admissions, multiple chronic conditions, major organ transplant candidates, and major trauma. A member identified for Complex Case Management is considered a participant in the program unless the member decides to opt-out (not accept the services/coordination of care offered). Once a nurse Case Manager evaluates a member, the Case Manager creates a care plan with the member and healthcare team input. The care plan is shared with the member’s doctor for input and review. The care plan is monitored by the Case Manager and coordinated with the member and doctor.
Coordinating Your Care Your primary care physician is your main contact for maintaining good health and receiving medical care, so selecting a doctor and establishing a strong relationship with them is essential for your well-being. Your doctor monitors your health and ensures you see the appropriate specialists when necessary. One of your primary care doctor’s responsibilities is coordinating all of your medical care. If you are receiving services from more than one practitioner or getting care from a specialist, it is 14
Member Newsletter
important for all your doctors to communicate valuable information with each other so they can work together to help ensure your care is complete and effective.
How can you help?
Please talk to your practitioner about sharing essential medical information with your PCP by requesting to sign a release of information. Share with your PCP the names and contact information of your other treating medical practitioners, so your PCP can request medical records.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
DISEASE MANAGEMENT SERVICES The VCHCP Disease Management Program coordinates health care interventions and communication
for members with conditions where VCHCP support of member self-care activities can improve their conditions. VCHCP has two Disease Management programs: Asthma and Diabetes. VCHCP has systematic processes in place to proactively identify members who may be appropriate for these disease management services. Diagnosis information on claims encounter data and pharmacy data prescription drug information are used to systematically identify members for disease management. Members and providers may also refer to the applicable Disease Management program. Once identified, the member is automatically enrolled in the program unless the member chooses to opt out. The Disease Management team works with doctors and licensed professionals to improve these chronic conditions, so members obtain the best possible quality of life and functioning. Included in the Disease Management Program are mailed educational materials, provider education on evidence-based clinical guidelines, member education over the phone (health coaching) and care coordination. VCHCP has a variety of member materials about diabetes and asthma available to help you better understand your condition and manage your chronic disease. Our goal is to improve the health of our members.
The VCHCP programs for Case Management and Disease Management are for members with severe illnesses and chronic diseases to help plan their care with their primary doctor and learn more about self-care. These programs have nurses who work with members over the phone to guide them towards the best possible health for their conditions. Participation in these programs is free and voluntary for eligible members. Members can opt out at any time and being in these programs does not affect benefits or eligibility. For more information or to submit a referral for the Case Management and Disease Management Program, please call 805-981-5060. Members can also self-refer to a program online on the Member page by clicking this link vchcp. venturacounty.gov/request-case-management-or-disease-management.
Accessing Services for Behavioral Health Contact OptumHealth Behavioral Solutions of California at (800) 851-7407 or visit the website at liveandworkwell.com/en/public Contact VCHCP Member Services at (805) 981-5050 to request an EOC copy or go to the Plan’s website at vchcp.venturacounty.gov/2026-EOC-Commercial.
Optum contact information can also be found at the back of your VCHCP health insurance card. Information on authorization of Plan Mental Health and Substance use benefits is available by calling the Plan’s Behavioral Health Administrator (BHA) at (800) 851-7407. A Care Advocate is available twenty-four (24) hours a day, seven (7) days a week to assist you in accessing your behavioral healthcare needs.
Further information may also be obtained by consulting your Ventura County Health Care Plan Commercial Members Combined Evidence of Coverage (EOC) Booklet and Disclosure Form. Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
15
Case Management How Does Case Management Benefit the Member? Case management provides a consistent method for identifying, addressing, and documenting the health care and social needs of our members along the continuum of care. Once a member has been identified for case management, a nurse will work with the member to:
Case Management is a process designed to coordinate services more efficiently, to provide a delivery methodology for targeted populations at risk, and to promote an interdisciplinary approach to meeting member needs throughout an episode of illness or continuum of care. It includes elements of behavioral change and selfmanagement. VCHCP licensed healthcare professionals collaborate with members, families, and providers to evaluate the appropriateness of care in the most cost-effective setting without compromise to quality care. The goal of VCHCP’s Case Management program is to help members regain health and functional capability.
Who Qualifies for Case Management/ Members Appropriate for Referral to Case Management? Case Management is provided to eligible members with specific diagnosis or special health care needs. This includes members with complex acute and chronic diagnoses, or specialty care management needs. These members typically require extensive use of resources and need assistance in navigating the healthcare delivery system. Members appropriate for case management referral include those members with medical and psychosocial needs impacting their compliance with disease management and health improvement including increasing severity of condition, safety issues, decreasing functional status, new behavioral health issues, and/or need for caregiver resources. Services are free and voluntary for eligible members. Members consent to being in the program but can opt out at any time. Being in the program does not affect benefits or eligibility.
16
Member Newsletter
• Complete a comprehensive initial assessment. • Determine benefits and resources available to the member. • Develop and implement an individualized care plan in partnership with the member, the member’s physician, and family or caregiver. • Identify barriers to care. • Monitor and follow-up on progress toward care plan goals.
How to Make a Referral to Case Management If a provider identifies a VCHCP member needing case management, or has questions regarding the Case Management Program, the provider can make a direct referral by contacting VCHCP’s Case Management Department at (805) 981-5060, or (800) 600-8247. The VCHCP Case Manager can confirm if the member has an open case management case and works with physician/provider to coordinate the care plan. If a case is not open, the VCHCP Case Manager will confirm member demographics and clinical information to initiate referral and assist the provider/physician with care coordination, as appropriate. Members and caregivers can contact Member Services at (805) 981-5050 and request a referral for case management services. Members can also self-refer to a program online on the Member page at vchcp. venturacounty.gov/request-case-management-ordisease-management. Hospital discharge planning staff may contact the VCHCP Concurrent Review Nurse or VCHCP Case Manager to initiate a case management referral by calling the VCHCP’s Case Management Department at (805) 981-5060. The VCHCP Concurrent Review Nurse/VCHCP Case Manager can confirm if the member has an open case management case and works with the Discharge Planner to coordinate care plan. If a case is not open, the Concurrent Review Nurse/VCHCP Case Manager will confirm member demographics and clinical information to initiate referral and assist with care coordination, as appropriate.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
TAR Process
WHAT DOES “PENDED FOR ADDITIONAL INFORMATION” MEAN? If your Treatment Authorization Request (TAR) is “pended for additional information”, it means we need more information from your health care provider before we can make a decision. What Happens Next? 1. We will let you and your provider know. • We will send a letter to you and your provider. o The letter will explain: ◊ That your request is on hold. ◊ What information is needed. ◊ That your provider has up to 45 days* to send us the missing information for a routine request. 2. If we get the information within 45 days: o We will review it. o We will make a decision within 5 business days. o You and your provider will be notified of the decision within 24 hours after it is made. 3. If we do not get the information within 45 days: o We will make a decision using the information we already have.
o If there is not enough information, the request may be denied. How Your Provider Can Help Your provider can help avoid delays by sending: • Notes from your most recent visit(s) related to your request. •
Important test or lab results.
•
Your treatment plan.
•
Clear, easy-to-read medical records.
If your provider uses Cerner, they can tell us exactly where to find the needed information in your medical record. If your provider is part of Ventura County Medical Center (VCMC), we will also send a message through Cerner when more information is needed. For providers outside VCMC, we will call the provider’s office. Our goal is to review your request as quickly as possible and keep you informed throughout the process.
If you have any questions, please contact VCHCP Utilization Management Department at: (805) 981-5060.
* These timeframes apply in most cases. If your request is urgent or for care you have already received, the review time may be different. Please see the VCHCP TAR Form for the timeline descriptions. Link: vchcp.venturacounty.gov/preAuthorizationTreatmentAuthorizationForm Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
17
VENTUR A COUNT Y HEALTH C ARE PL AN’S
Referral & Prior Authorization Process and Services Requiring Prior Authorization Need information on how and when to obtain referrals and authorization for specific services? We’ve got you covered! Not sure how or when to get a referral or authorization for certain services? Visit the VCHCP website (vchcp.venturacounty.gov), go to the Members section on the top of the page, and select Referrals and Prior Authorizations. Or you can go directly to the information by clicking this link: vchcp.venturacounty.gov/PriorAuthorizationProcess. This area provides links for members to obtain specific information on the Plan’s prior authorization process, what services require prior authorization, timelines, and direct referral information. IF YOU HAVE ANY QUESTIONS, PLEASE CALL MEMBER SERVICES AT (805) 981-5050.
UNDERSTANDING YOUR PHARMACY BENEFITS VCHCP partners with Express Scripts, inc. (ESI) to manage the pharmacy benefits for VCHCP members. Your covered prescriptions can be filled at any contracted pharmacy, and in some cases, via mail order. A listing of the local contracted pharmacies is available on the VCHCP website: vchcp.venturacounty.gov/ESIPharmacyListbyName Additionally, your pharmacy benefit includes access to contracted pharmacies through-out the United States, so you can obtain covered medications even when you are outside of Ventura County. You can access the list of contracted pharmacies outside of Ventura County by visiting the Express Scripts Website: express-scripts.com or by contacting ESI at (800) 811-0293. As a VCHCP member, you are encouraged to create an account on the ESI website or by downloading the Express Scripts App on your phone. On the ESI website you have access to the pharmacy list, ordering refills, reviewing medication alternatives, pricing medications and much more. If you have any questions, please contact our Member Services team at (805) 981-5050.
18
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Find your path to a happier, healthier you You may have heard about or even used the Calm app. Now you have access to its most popular features and much more with Calm Health. Available through your behavioral health benefits at no additional cost to you, it’s packed with content. And it’s all self-paced with video and audio tools, so you can go at your own speed — 24/7. Support for mind and body All programs, courses and tools are designed to strengthen the connection between your body and mind. They offer mental health guidance and compassionate support for a wide range of health and wellbeing goals. Self-care courses and tools Work toward wellbeing goals like: •
Getting better sleep to start your days refreshed
•
Building skills to help with stress and anxiety
•
Developing resiliency to navigate life’s uncertainties
•
Practicing mindfulness for improved focus, movement and clarity
Personalized plan With short screenings, you can understand where you are in your journey and get a more personalized experience. Based on your responses, you also may receive recommendations for additional solutions and services from your health plan, such as coaching or therapy.
Explore the benefits: •
Curated content tailored to you and your journey
•
Self-guided to go at your own pace
•
No additional cost to you
Get started today To register and download the Calm Health app, scan the QR code. When prompted, enter access code: Health. Enter your member ID, name and date of birth.
Calm and Calm Health should not be used for urgent care needs. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room. If you are experiencing a non-life-threatening mental health crisis, call or text 988. Calm and Calm Health are not intended to diagnose or treat depression, anxiety or any other mental or physical health condition. The use of Calm or Calm Health is not a substitute for care by a physician or other health care provider. Any questions that you may have regarding the diagnosis, care or treatment of a health condition should be directed to your physician or health care provider. Calm and Calm Health are mental wellness products. Participation is voluntary and subject to the Calm and Calm Health terms of use. Optum is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. © 2026 Optum, Inc. All rights reserved. WF14028110 323916A-112025
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
19
What is Optum’s Complex Case Management Program? Optum offers a Complex Case Management program to help members through more intensive coordination of services. This program is intended to help people with complex behavioral health conditions connect with needed services and resources. Behavioral Health Advocates work intensely with you or your loved one in the development of a comprehensive plan of care which coordinates the following: • Therapeutic services (therapy, medication management, case management, etc.) • Community and Psychological supports (education/support regarding illness, coordination with support system, other supportive services • Coordination of care between medical and behavioral physicians and clinicians • Recovery and Resiliency services (peer support, development of a crisis/recovery plan, life planning activities) • Other services as appropriate (legal, shelter, basic needs, etc.)
Program Goals: • Movement to recovery • Enhanced wellness • Building resiliency through self-care and empowerment Criteria for acceptance into the program include: • Presence of complex behavioral health condition(s) which require a greater level and intensity of services • History of intensive behavioral health service utilization over the past 12 months • Willingness to actively participate in the program for at least 90 days If you believe you or a loved one meet these criteria and would benefit from Optum’s Complex Case Management program, please contact Optum via the toll-free number on the back of the member’s insurance card to ask for this program. Optum looks forward to partnering with you or your loved one on the path to recovery and wellness.
How we make decisions about benefit coverage All our staff follow strict rules when they decide about approval of benefits. Decisions are based on what your benefits cover and your medical needs. We do not reward staff or healthcare providers for saying “no” to care or services. We do not give financial rewards to our staff or healthcare providers to make decisions that result in less care or service than what is needed.
How to contact us Our offices are open Monday through Friday. Our hours are from 8 a.m. to 5 p.m., except on holidays. You can call the toll-free number on your insurance card or health plan member ID card to learn about your benefits or get approval for care. Optum offers language assistance, at no added cost for members who prefer to speak a language other than English. Our offices have toll-free numbers for members with hearing impairments. You can also get help with services or ask questions. A Care Advocate can answer your questions about services and our decisions. Our staff will tell you their name, title, and where they work. If you have an emergency or urgent health concern, seek immediate attention or call 9-1-1. You can always contact one of our Care Advocates 24 hours a day, 7 days a week. You can even speak to a Care Advocate on weekdays and holidays. To call us, use the toll-free number on your health insurance card or health plan member ID card or in your benefits booklet or Evidence of Coverage. 20
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
What are my rights and responsibilities? 1. Members have a right to receive information about the organization, its services, its network clinicians, and members’ rights and responsibilities.
15. Members have a right to participate in the consideration of ethical issues that arise in the provision of care and services, including:
2. Members have a right to be treated with respect and recognition of their dignity and right to privacy.
• Resolving conflict.
3. Members have a right to participate with network clinicians in making decisions about their health care.
• Forgoing or withdrawing life-sustaining treatment.
4. Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. 5. Members have a right to voice complaints or appeals about the organization of services it provides. 6. Members have a right to make recommendations regarding the organization’s members’ rights and responsibilities policies. 7. Members have a responsibility to supply information (to the extent possible) that the organization and its network clinicians need in order to provide care. 8. Members have a responsibility to follow plans and instructions for care that they have agreed on with their network clinicians.
• Withholding resuscitative services. • Participating in investigational studies or clinical trials. 16. Members have a right to designate a surrogate decision-maker if the member is incapable of understanding a proposed treatment or procedure or is unable to communicate his or her wishes regarding care. 17. Members and their families have a right to be informed of their rights and responsibilities in a language they understand. 18. If a member chooses not to comply with recommended care, treatments, or procedures, the clinician is to inform the member of the potential consequences of not complying with the treatment recommendations. 19. Members have a right to be informed of rules and regulations concerning their own conduct.
9. Members have a responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
20. Members have a right to be informed of the reason for any adverse determination, including the specific utilization review criteria or benefit provisions used in the determination.
10. Members have a right to care that is considerate and that respects their personal values and beliefs systems.
21. Members have a right to have utilization management decisions made based on appropriateness of care. The organization does not reward network clinicians or other individuals conducting utilization review for issuing adverse determinations for coverage or services.
11. Members have a right to personal privacy and confidentiality of information. 12. Members have a right to reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age, or disability. 13. Members have a right to have their family members participate in treatment planning. Members over 12 years old have the right to participate in such planning. 14. Members have a right to individualized treatment, including: • Adequate and humane services regardless of the source(s) of financial support. • Provision of services within the least restrictive environment possible. • An individualized treatment or program plan. • Periodic review of the treatment or program plan. • An adequate number of competent, qualified, and experienced professional clinicians to supervise and carry out the treatment or program plan.
22. Members have a right to: • Inspect and copy their protected health information (PHI). • Request to amend their PHI. • Request an accounting of non-routine disclosure of PHI. • Request limitations on the use or disclosure of PHI. • Request confidential communications of PHI to be sent to an alternate address or by alternate means. • Make a complaint regarding use or disclosure of PHI. • Receive a Privacy Notice. 23. Members have a right to receive information about the organization’s clinical guidelines and Quality Improvement program.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
21
A MESSAGE FROM OUR Case Management Nurse Case Management (CM) is part of your VCHCP benefit, free of charge to all members. I am dedicated to assist in organizing your healthcare need(s) and assist with coordinating care you may need. I can communicate between your providers to help connect your care and achieve your health goals. I am your advocate and I will help to empower you to manage your health care needs. If you are “lost” in the system of navigating your health care needs, contact CM to discuss your options. If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Manager or Disease Manager. Your call will be returned within 2 business days. Members can also self-refer to the program online on the Member page at vchcp.venturacounty.gov/request-casemanagement-or-disease-management or by scanning this QR Code.
How Often Should You See Your
Primary Care Provider? Your Primary Care Provider (PCP) is responsible for treating you when you are sick or injured, and at times is the coordinator of referrals to specialists and other services. Some members rarely see their PCP, which can make care difficult, especially in an emergent situation. Children and Adults should be seen by their PCP at least yearly (more frequently for children under 2 years of age). Preventive Health Visits, or Check-ups, should occur regularly to have appropriate preventive screenings, immunizations, and an overall review of your health. This is an important visit to discuss health concerns or even health goals. Staying in contact with your PCP by having annual check-ups can help with establishing a good relationship with your PCP. This relationship can make times of illness or injury run smoother and give you peace of mind for the care you receive.
If you haven’t had a checkup in the last year, please call your PCP today to make an appointment. If you need assistance or have questions, please call Member Services at (805) 981-5050. 22
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
New Medical Technology VCHCP’s Medical Director, or designee, evaluates new technology that has been approved by the appropriate regulatory body, such as the Food and Drug Administration (FDA) or the National Institutes of Health (NIH). Scientific evidence from many sources, specialists with expertise related to technology and outside consultants, when applicable, are used for the evaluation. The technology must demonstrate improvement in health outcomes or health risks, the benefit must outweigh any potential harm, and it must be as beneficial as any established alternative. The technology must also be generally accepted as safe and effective by the medical community and not investigational. For help with new medication evaluations, the Plan
looks to our Pharmacy Benefit Manager, Express Scripts, for their expertise. For new behavioral health procedures, the Plan uses evaluations done by our Behavioral Health delegate, OptumHealth Behavioral Solutions of California (also known as Life Strategies). Once new technology is evaluated by the Plan, the appropriate VCHCP committee reviews and discusses the evaluation and makes a final decision on whether to approve or deny the new technology. This final decision may also determine if any new technology is appropriate for inclusion in the plan’s benefit package in the future. For any questions, please contact the VCHCP Utilization Management Department at (805) 9815060.
® Get Get your your OneTouch OneTouch® meter meter today! today! ® How How to to get get your your OneTouch OneTouch® meter: meter:
Use your insurance: OneTouch®® products are covered by most Use your insurance: OneTouch products are covered by most US insurance plans, often with low or no co-pay.* US insurance plans, often with low or no co-pay.* No insurance or your plan doesn’t cover OneTouch®® products: No insurance or your plan doesn’t cover OneTouch products: Bring this voucher and your prescription to your pharmacy to receive Bring this voucher and your prescription to your pharmacy to receive a OneTouch®® blood glucose meter for a $10 co-pay. a OneTouch blood glucose meter for a $10 co-pay.
Voucher valid with OneTouch Voucher valid with OneTouch Verio Flex®® and OneTouch and OneTouch Verio Flex Ultra®® 2 meters only. Ultra 2 meters only.
OneTouch® OneTouch® meters meters and and test test strips strips are are the the #1 #1 Doctor Doctor recommended† recommended† and customers' most-trusted‡ brand in the US. and customers' most-trusted‡ brand in the US. COPAY: COPAY: $10 $10
BIN: BIN: 601341 601341
RxPCN: RxPCN: OHCP OHCP
Group ID#: Group ID#: OHLC01021 OHLC01021
ID#: ID#: Y23100136180 Y23100136180
Patients: Patients: • Offer good while supplies last. Void where prohibited by law. Offeroffer good while suppliesInc. last.can Void where prohibitedwhere by law. •• This from LifeScan, only be redeemed OneTouch® products are sold and prescriptions can be processed. • This offer from LifeScan, Inc. can only be redeemed where OneTouch® products are sold and prescriptions can be processed. Pharmacist: Pharmacist: • Requires a valid prescription. Offer valid for one meter per patient every 36 months. •• Requires a valid valid for one meter per patient every 36 months. Submit this claimprescription. to IQVIA forOffer reimbursement plus a dispensing fee. Questions? Call 1-800-364-4767. Submit this claimintothis IQVIA for reimbursement plus a dispensing fee. Questions? •• By participating program or by otherwise processing a program voucher, Call you 1-800-364-4767. warrant that you will not submit a claim • By participating in this program or by otherwise processing a program voucher, warrant that will not submit a claim for reimbursement of any meter covered by this agreement with any commercialyou payor or state oryou federal government funded for reimbursement any covered by this Medicare agreement with any commercial payor or VA, state or federal government funded ® program (includingof but notmeter limited to Medicare, Advantage, Medicaid, Medigap, DOD, or TriCare ). ® butthe notright limited to Medicare, Medicare Advantage, or TriCareat ).any time • program Lifescan, (including Inc. reserves to rescind, revoke, or amend this offer,Medicaid, program Medigap, eligibility, VA, andDOD, requirements • Lifescan, Inc. reserves the right to rescind, revoke, or amend this offer, program eligibility, and requirements at any time without notice. without notice. * MMIT Formulary Report July 2025. Some health plans may have more than one test strip * MMIT Formulary Report July 2025. Some health plans may have more than one test strip covered at the lowest co-pay. covered at the lowest co-pay. † Based on Symphony Health Solutions Manufacturer Market Share Prescribing Data, June '25. † Based on Symphony Health Solutions Manufacturer Market Share Prescribing Data, June '25. ‡ Voted #1 most trusted Blood Glucose Monitor brand by American shoppers based on the ‡ Voted #1 most trusted Blood Glucose Monitor brand by American shoppers based on the 2025 BrandSpark® American Trust Study. 2025 BrandSpark® American Trust Study. © 2026 LifeScan Enterprise LLC. All rights reserved. US-OTB-2500004 © 2026 LifeScan Enterprise LLC. All rights reserved. US-OTB-2500004
Scan Scan QR QR code code for an electronic for an electronic version version of of voucher voucher
US-OTB-2500004 US-OTB-2500004
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
23
Wellness Wire Diabetes & Heart Health
Understanding the Use of Statins in Diabetes
People with diabetes are at a higher risk for heart disease and stroke. Even when cholesterol numbers appear normal, diabetes can damage blood vessels over time, increasing the chance of plaque buildup in the arteries. Because of this, taking care of your heart is an important part of managing diabetes. Statins are commonly used medications that help lower “bad” (LDL) cholesterol and reduce plaque buildup in your arteries, which can help protect against heart attacks and strokes.
2x
Taking steps to protect your heart is an important part of managing diabetes. Medications, like statins, and healthy habits can work together to support long-term health.
Did you know? People with diabetes are twice as likely to develop heart disease, even if they don’t have symptoms. Taking care of your heart is just as important as managing your blood sugar. That’s why statins are often recommended as part of routine diabetes care. Here are 2 links where you can learn more:
Diabetes and Comorbidities Learn more: Statins and Diabetes – What You Should Know
Are Statins Safe?
For most people with diabetes, the heart-protective benefits of outweigh the risks, and serious side effects are rare. Your healthcare provider can help you find an option that works best for you.
Manage blood sugar and take medications appropriately
CardioSmart.org/Cholesterol All Evernorth Health Services products and services are provided exclusively by or through affiliates of the Evernorth companies, including Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Evernorth Behavioral Health of Texas, Inc. and Evernorth Behavioral Health of California, Inc. © 2026 Evernorth Health Services. All rights reserved. Some content provided under license. All pictures are used for illustrative purposes only.
24
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Milliman Care Guidelines & Medical Policy Updates
VCHCP Utilization Management uses Milliman Care Guidelines 30th Edition, VCHCP Medical Policies, and VCHCP Prior Authorization Drug Guidelines as criteria in performing medical necessity reviews. Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, but a hard copy of an individual guideline can be provided as requested. A complete listing of new and updated VCHCP medical policies, and prescription drug policies are posted on The Plan’s website at: vchcp.venturacounty.gov/medical-policies. To obtain printed copies of any of our VCHCP Medical/Drug Policies or Milliman Care Guidelines, please contact Member Services at (805) 981-5050 or at (800) 600-8247.
2026 QUALITY IMPROVEMENT
Program Evaluation
Each year, the Health Plan evaluates its success in accomplishing identified goals for the prior year, including, but not limited to, its ability to meet regulatory standards specified by the Department of Managed Health Care (DMHC). For 2025, the Plan is pleased to share that it succeeded in achieving multiple identified goals. To view the summary of our Quality Improvement Program Evaluation, please click this link: vchcp.venturacounty.gov/AnnualQualityAssuranceProgramOverview/
Clinical Practice Guidelines VCHCP encourages its providers to practice evidence-based medicine. VCHCP has links to clinical practice guidelines available to address conditions frequently seen in patients at their practice. All clinical practice guidelines included have been reviewed and approved by the VCHCP Quality Assurance Committee.
Recommended Clinical Practice Guidelines and links for providers: • Clinical Practice Guidelines • 2 Medical Conditions: Asthma & Diabetes
• Preventive Guidelines For All Age Groups o Perinatal Care Guidelines
o Joslin Diabetic Center and Joslin Clinic
o U.S. Preventive Services Task Force (USPSTF)
o American Diabetes Associates (ADA) at diabetes.org
o Advisory Committee on Immunization Practices (ACIP)
o National Asthma Education and Prevention Program o Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma
• Non-profit Professional Society, Standards of Care developed by the World Professional Association for Transgender Health (WPATH) o wpath.org/publications/soc8
• 1 Behavioral Health Conditions: Depression o American Psychiatric Association
You may obtain hard copies of the above-listed Clinical Practice Guidelines by calling VCHCP at (805) 981-5050 The guidelines are also available on VCHCP’s website at: vchcp.venturacounty.gov/quality-management. Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
25
Breast Cancer Screening You may also see this information about Breast Cancer Screenings in the Plan’s Preventive Health Guidelines brochure. To view the brochure, please visit the VCHCP website at: vchcp.venturacounty.gov/wp-content/uploads/2023/03/preventiveHealthGuidelinesCommercial.pdf#page=6.
Contact one of the following providers to discuss the care that is appropriate for you: Your VCHCP Primary Care Provider | Your VCHCP OB/GYN Provider KEY FACTS:
• Mammograms can find breast cancer early, when it’s easier to treat. • Most breast lumps are not caused by cancer; many conditions can cause them. • Breast cancer symptoms vary, and some women don’t have symptoms. • Men can get breast cancer, but it is not very common. For every 100 cases of breast cancer, less than 1 is in men. PREVENTION TIPS:
• Keep a healthy weight and exercise regularly. • Limit the amount of alcohol you drink. • If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks and find out if it is right for you.
• Know
your family history of breast cancer. If you have a close relative with breast cancer, ask your doctor how you can manage your risk.
• A mammogram can’t prevent breast cancer, but it can help find it early. Talk to your health care provider about whether screening is right for you.
• Breast cancer screening means checking a woman’s breasts for cancer before she has any symptoms. A mammogram is an X-ray picture of the breast. Mammograms are the best way to find breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms. • Most women who are 40 to 74 years old should have a screening mammogram every two years. If you think that you may have a higher risk of breast cancer, ask your doctor when to have a screening mammogram.
Content source: Centers for Disease Control and Prevention
EARLY DETECTION IS THE BEST PRACTICE AGAINST CANCER, ESPECIALLY BREAST CANCER. To increase awareness, VCHCP mails mammogram post cards to those who are due for their breast cancer screening. The postcards were mailed in June, and will be mailed again in October 2026. Our goal is to provide education to you to complete this important screening. Please bring this postcard to your doctor during your office visit to discuss more about your breast cancer screenings.
If you have any questions or concerns, please contact our Health Services Department at (805) 981-5060. 26
Schedule Your Screening Mammogram No doctor’s order or VCHCP approval VCHCP Network Radiology Facilities needed. Schedule a screening with any VCHCP Ventura County Medical Center Radiology (VCMC) contracted radiology facility. (805) 652-6080 M-F: 8AM – 3:30PM No copay for screening mammograms at any Extended Hours: Open until 6:30PM contracted facility. Mammogram does not on select Tues. and Thurs., and one require prior authorization. Sat. morning per month.
Santa Paula Hospital Radiology Center
Call ahead to confirm availability and hours, as they vary by location.
(805) 652-6080
Recommended Screening Schedule VCHCP and the U.S. Preventative Services Task Force recommends a screening every 2 years for women ages 40–74.
(805) 357-0067 Press Option 1
Reminder: Please request that your results be sent to your primary care doctor. Copay applies for diagnostic mammograms.
Bring this card to your appointment and give it to the radiology office.
Member Newsletter FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
M-F: 7:30AM – 3PM Same-day appointments may be available.
Rolling Oaks Radiology
Ventura – 2705 Ventura – 4516 Camarillo Oxnard – 1901 Rice Ave Oxnard Outlet Center Thousand Oaks – 415
TU, W: 8:30AM–4:30PM M–F: 7AM–5:30PM TU, TH: 8AM–4:30PM M–F: 8AM–4:30PM TU, TH: 8AM–4:30PM M–F: 7AM–4PM
Rolling Oaks St. John’s Imaging Center
(805) 983-0883
M, Tu, Th, F: 8am –6pm
Colorectal Cancer Screening You may also see the information below about Colorectal Cancer Screenings in the Plan’s Preventive Health Guidelines brochure. To view the brochure, please visit the VCHCP website at: vchcp.venturacounty.gov/ members/docs/healthEducationInfo/preventiveHealthGuidelinesCommercial.pdf#page=7
Contact your VCHCP Primary Care Provider to discuss the care that is appropriate for you. KEY FACTS: • The best way to reduce your colorectal cancer risk is to get screened regularly beginning at age 45. • Colorectal cancer affects men and women of all racial and ethnic groups. • Colorectal polyps and colorectal cancer don’t always cause symptoms, especially at first. PREVENTION TIPS: • If you’re 45 years old or older, talk to your doctor about getting screened.
stool (bowel movement); stomach pain, aches, or cramps that don’t go away; or are losing weight and you don’t know why.
• If you’re younger than 45 years old but may have a higher risk of colorectal cancer, ask your doctor if you • Presently, the recommendation for colorectal should start screening before age 45. screening is to begin at age 45 or older, and sooner • Learn your family history of cancer and tell your for those who are at high risk for developing doctor if you think you may have a higher risk. colorectal cancer. Special screening programs are • Don’t smoke. Contact your VCHCP Primary Care used for those with family history of colorectal cancer Provider to discuss the care that is appropriate for and for those who are at high risk. There are several you. acceptable methods for colorectal cancer screening • Get enough physical activity and limit your alcohol which includes fecal occult blood testing annually, consumption. sigmoidoscopy every 5 years or colonoscopy every • Talk to your doctor if you have blood in or on your 10 years. Content source: Centers for Disease Control and Prevention
EARLY DETECTION IS THE BEST PRACTICE AGAINST CANCER, ESPECIALLY COLORECTAL CANCER. To increase awareness, VCHCP will mail postcards (October/November 2026) to all members who are due for
their
colorectal
cancer
screenings. Our goal is to provide education to our members and
Your Gut Deserves the Spotlight Checking your colon is easier than you think.
(Some people at higher risk may start sooner) Recommended by VCHCP and the U.S. Preventive Task Force
FIT or Stool DNA test kits — noninvasive and easy to do at home. These tests check for hidden blood or DNA changes in stool samples. Repeat every 1–3 years, depending on the test type.
encourage them to complete these important screenings.
Colonoscopy — allows your doctor to examine the large intestine for abnormalities. Preparation and sedation are required, and you’ll need a ride home afterward. Repeat every 10 years.
Please bring this postcard to your doctor’s visit to discuss more about your colorectal cancer screenings.
If you have any questions or concerns, please contact Utilization Management at (805) 981-5060.
Ask your doctor about colorectal cancer screening starting at age 45, and ask which test is right for you.
Questions? Please contact VCHCP Utilization Management (805) 981-5060
CT Colonography — uses special X-ray imaging to look inside the large intestine for cancer or polyps. Repeat every 5 years. Flexible Sigmoidoscopy — views the rectum and lower colon. Similar to a colonoscopy, and usually done every 5 years or 10 years if combined with a yearly FIT test. 10/2025
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
27
Diabetic Retinal Exam What is a diabetic retinal exam?
A diabetic retinal exam lets your eye doctor see the back of your eye (retina). It helps find eye problems such as diabetic retinopathy. This problem occurs when high blood sugar from diabetes damages the small blood vessels in the retina.
Diabetes eye exams
Diabetes can harm your eyes. It can damage the small blood vessels in your retina, the back wall of your eyeball. This condition is called diabetic retinopathy. Diabetes also increases your risk of glaucoma and other eye problems.
You may not notice that your eyes are damaged until the problem is very bad. Your eye doctor can catch problems early if you get regular eye exams. This is very important. The early stages of diabetic retinopathy don’t cause changes in vision and you won’t have symptoms. Only an eye exam can detect the problem, so steps can be taken to prevent the eye damage from getting worse. REFERENCES:
You Need Regular Eye Exams
Even if the health care provider who takes care of your diabetes checks your eyes, you need an eye exam every 1 to 2 years by an eye doctor who takes care of people with diabetes. An eye doctor has equipment that can check the back of your eye much better than your regular provider can. If you have eye problems because of diabetes, you will probably see your eye doctor more often. You may need special treatment to prevent your eye problems from getting worse. You may see two different types of eye doctors: • An ophthalmologist is a medical doctor who is an eye specialist. • An optometrist is a Doctor of Optometry. If you develop eye disease caused by diabetes, you will likely also see an ophthalmologist.
medicine taste in your mouth. Your eyes will have trouble focusing for up to 6 hours after the test. This will likely affect your near vision more than your far vision.
Your eyes may be sensitive to light. Wearing sunglasses may help until the drops wear off. Do not drive for a few hours after the test, unless your doctor says it is okay.
If your eye exam results are normal, your doctor may do follow-up exams every 2 years instead of every year. But if you have diabetic retinopathy, you may need eye exams more often. Please share your eye exam results with your PCP and endocrinologist. Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments and call your doctor if you are having problems. Ask your doctor when you can expect to have your test results.
What happens after the exam?
Dilating drops may make your eyes sting. This will last for a few moments. They may also cause a
Healthwise. 2024. Diabetic Retinal Exam: About This Test. healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.diabetic-retinal-exam-about-this-test.acn4674 MedlinePlus. 2023. Retina. medlineplus.gov/ency/article/002291.htm MedlinePlus. 2024. Diabetes eye exams. medlineplus.gov/ency/patientinstructions/000323.htm MedlinePlus. 2023. Diabetes and eye disease. medlineplus.gov/ency/article/001212.htm MedlinePlus. 2024. Glaucoma. medlineplus.gov/ency/article/001620.htm Asthma
yout 1
1.qxd:La
Broch-3.
2/5/09
Page 1
4:01 PM
written by
ol
ical Scho Harvard Med
EDUCATION EDUCATION MATERIALS MATERIALS
To access To access the the Plan’s Plan’s useful useful andand current current educational educational materials, materials, please please clickclick on this on this link:link: vchcp.venturacounty.gov/health-info vchcp.venturacounty.gov/health-info 28
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Asthmeato Breathing Easier Your Guid
ntedu.org
www.patie
Direct Specialty REFERRALS A “Direct Specialty Referral” is a referral that your Primary Care Physician (PCP) can give to you so that you can be seen by a specialist physician or receive certain specialized services. Direct Specialty Referrals do not need to be pre-authorized by the Plan. All VCHCP contracted specialists can be directly referred by the PCPs using the direct referral form (EXCLUDING TERTIARY REFERRALS, [e.g. UCLA AND CHLA]). Referrals to Physical Therapy and Occupational Therapy also use this form. Note that this direct specialty referral does not apply to any tertiary care or non-contracted provider referrals. All tertiary care referrals and referrals to non-contracted providers continue to require approval by the Health Plan through the treatment authorization request (TAR) procedure.
Appointments to specialists when you receive a direct referral from your PCP should be made either by you or by your referring doctor. Make sure to check with your referring doctor about who is responsible for making the appointment. Appointments are required to be offered within a specific time frame, unless your doctor has indicated on the referral form that a longer wait time would not have a detrimental impact on your health. Those timeframes are: Non-urgent within 15 business days, Urgent within 48-96 hours. If you or your doctor feel that you are not able to get an appointment within an acceptable timeframe, please contact the Plan’s Member Services Department at (805) 981-5050 or (800) 600-8247 so that we can make the appropriate arrangements for timeliness of care.
The Direct Referral Policy can also be accessed at: vchcp.venturacounty.gov/DirectSpecialtyReferral To request to have a printed copy of the policy mailed to you, please call Member Services at the numbers listed above.
REQUEST Complex Case Management, Case Management or Disease Management In addition to VCHCP medical management staff, hospital discharge planners and practitioners; members and caregivers now have an opportunity to seek assistance for complex and or chronic medical needs such as asthma, diabetes, and coordination of challenging care online! Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, facilitation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
VCHCP’s CCM program is an opt-out program, and all eligible members have the right to participate or decline participation. Verbal consent is obtained prior to formally enrolling the member into the Complex Case Management Program. Members who are identified with the following situations include but are not limited to: Transplants, ESRD, Traumatic Brain Injuries and High-Risk Diabetics. For a detailed information regarding complex case management, please refer to the policy and procedure on VCHCP’s website: vchcp.venturacounty.gov/ComplexCaseManagementPolicy
Members and caregivers can contact Member Services at (805) 981-5050 and request a referral for case management or disease management services. Members can also self-refer to a program online on the Member page at vchcp.venturacounty.gov/request-case-management-or-disease-management. You will be prompted to enter member specific information. You will then submit this form to a secure email. A nurse will evaluate your request and call you within 2 business days. If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
29
Post Inpatient DISCHARGE FOLLOW-UP Admission to a hospital, either planned or unexpected, can be difficult and often results in a change in your medication or treatment plan. After discharge from the hospital, it is very important that you make an appointment to see your Primary Care Provider (PCP) and specialist when applicable, as soon as possible, or within 30 days. This visit is to update your PCP and/ or specialist on what occurred that required you to be admitted to the hospital, update your medication routine, and to be referred to additional care if needed. Establishing and keeping a good relationship with your PCP is vital to your health and your PCP’s ability to provide care to you. If you feel you are having medical issues related to your recent hospitalization, for continuity of care, you should contact your doctor before going to the Emergency Room or if the issues are severe, like chest pain or sudden heavy bleeding, call 911. For less severe issues, we have several Urgent Care Centers in our network.
VCHCP will send all members discharged from an inpatient stay a targeted letter instructing them to
follow up with the specific time frame noted. Letters will also be sent to Providers to notify of members discharge from the hospital.
If you find that making an appointment with your
PCP or specialist after an inpatient hospital stay is
difficult and you can’t be seen within 30 days, please
notify your Ventura County Health Care Plan Member
Services Department at (805) 981-5050. Your ability to access health care is important to us.
OptumHealth QUALITY PROGRAM VCHCP contracts with OptumHealth Behavioral Solutions for mental/behavioral health and substance abuse services. OptumHealth has a Quality Improvement Program (QI) that is reviewed annually. If you would like to obtain a summary of the progress OptumHealth has made in meeting program goals, please visit OptumHealth’s online newsletter at vchcp.venturacounty.gov/OptumHealthNEWSLETTER or call OptumHealth directly at (800) 851-7407 and ask for a paper copy of the QM program description.
Adult Preventive Care Contact your VCHCP Primary Care Provider to make an appointment for your preventive care visit and to discuss the preventive care services that are appropriate for you.
Vaccinations for Adults - You’re NEVER too old to get vaccinated! Getting vaccinated is a lifelong, life-protecting job. Don’t leave your healthcare provider’s office without making sure you’ve had all the vaccinations you need. Information about Adult Preventive Health Visits/Care and a detailed list of vaccinations for adults are available in the Plan’s Preventive Health Guidelines brochure. To view the brochure, please visit the VCHCP website at: vchcp.venturacounty.gov/wp-content/uploads/2023/03/ preventiveHealthGuidelinesCommercial.pdf#page=6 30
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
EMPOWERING YOU IN LOW BACK PAIN CARE:
CHOOSING THE RIGHT APPROACH
When it comes to managing low back pain, choosing the right approach is crucial for your well-being. Low back pain can be caused by various factors, and not all cases require imaging studies, such as X-rays, MRIs, or CT scans.
Did you know that most low back pain cases can be diagnosed and treated without the need for imaging? At Ventura County Health Care Plan, we prioritize your health and aim to provide the most appropriate care. It is essential to understand that imaging studies may not always be necessary for low back pain and can lead to additional costs and potential risks. Instead, your healthcare provider will likely perform a thorough evaluation, considering your medical history, symptoms, and physical examination.
We encourage you to have an open conversation with your provider about your low back pain symptoms. Together, you can make informed decisions about the best course of action, which may involve non-invasive treatments like physical therapy, exercise, and pain management strategies.
Let’s work together in making informed decisions about your low back pain care and prioritize your well-being. References: 1. C leveland Clinic. (2024). Lower Back Pain. my.clevelandclinic.org/
health/diseases/7936-lower-back-pain 2. The American College of Physicians (ACP). (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline. acpjournals.org/doi/10.7326/M16-2367
Contact your VCHCP Primary Care Provider to discuss
Child Immunizations the vaccination that is appropriate for your child. VACCINES PREVENT DISEASE IN PEOPLE WHO OBTAIN THEM and protect those who come into contact with unvaccinated individuals. Vaccines are responsible for the control of many communicable diseases that were once widespread in this country, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, and Haemophilus influenza type b (Hib). Before vaccines, many children died from diseases that vaccines now inhibit, such as whooping cough, measles, and polio. Those same germs exist today, but babies are now protected by vaccines, so we do not see these diseases
as frequently. Immunizing individual children also improves the wellbeing of our community, especially those people who are not immunized. People who are not immunized include those who are too young to be vaccinated, those who cannot be vaccinated for medical reasons (example: children with leukemia), and those who cannot make a satisfactory response to vaccination. Information about child immunizations can be found by visiting the VCHCP’s website at vchcp.venturacounty.gov/wp-content/ uploads/2023/03/preventiveHealthGuidelinesCommercial. pdf#page=3
Omada Hypertension Program Ventura County Health Care Plan offers our members the opportunity to manage their high blood pressure without feeling overwhelmed. The ESI/Omada program offers the Omada Hypertension program, which includes digital support for members with high blood pressure. Members interested in becoming eligible and encouraged to enroll for the Omada Hypertension program are those individuals on high blood pressure medications. Members can use Omada program services after enrollment in the programs. Enrolled members are sent a blood pressure monitor and weight scale, and information on how to access the Omada digital app. The Omada digital app gives members access to healthy living and diet coaching,
food tracking, community groups, weight and blood pressure tracking, and learning modules to improve their well-being. Members can OPT into the Omada programs by using the link provided in the marketing materials or listed here omadahealth.com/express-scripts2 The link provided takes members to a clinical questionnaire page to enroll into Omada. After completing the questionnaire, and if the clinical criteria is met, the member is approved to enroll into the Omada program and can choose to participate. The Omada Program is an OPT-in program. Members can choose not to participate or can OPT out of the program at any time.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
31
FLU FACTS The staff at VCHCP want to make sure you have the facts about influenza and the yearly influenza vaccines so that you can make informed decisions regarding your health. Here is a fact sheet about the flu vaccine to help you make these decisions. FACT: Influenza (flu) is a potentially serious disease that can lead to hospitalization and sometimes even death. Common flu symptoms are fever, chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches and fatigue. Some people may have vomiting and diarrhea, more common in children than adults. Flu usually results in a few days of feeling bad and missing work, school, or family events; however, it can result in more serious illness. FACT: Every flu season is different, and flu can affect people differently, but during typical flu seasons, millions of people get flu, hundreds of thousands of people are hospitalized and tens of thousands of people die from flu-related causes. FACT: Signs and Symptoms of Flu can include bacterial pneumonia, ear infections, sinus infections and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. FACT: The flu vaccine has proven itself over the years to be safe and effective in most persons who receive it. FACT: A flu vaccine is needed every year for two reasons. First, a person’s immune protection from vaccination declines over time, so an annual flu vaccine is needed for optimal protection. Second, because influenza viruses are constantly changing, the composition of flu vaccines is reviewed annually, and vaccines are updated to protect against the viruses that research indicates will be most common during the upcoming flu season. FACT: The vaccines either contain inactivated virus, meaning the viruses are no longer infectious, or a particle designed to look like an influenza virus to your immune system. While the nasal spray flu vaccine does contain a live virus, the viruses are changed so that they cannot give you the flu. FACT: Adults with certain chronic conditions and pregnant women are at higher risk of developing serious complications from flu. If you are at higher risk, flu vaccination is especially important. When you get vaccinated, you reduce your risk of getting sick with flu and possibly being hospitalized or dying from flu. FACT: While some people who get a flu vaccine may still get sick with influenza, flu vaccination has been shown in several studies to reduce severity of illness. Vaccinated individuals who do get sick with flu typically experience milder symptoms than those who do not receive the vaccine. FACT: Most people do not experience serious side effects from flu vaccines. Some may experience a sore arm at the injection site, fever, muscle pain, and feelings of discomfort or weakness. These side 32
Member Newsletter
effects are usually mild and short-lasting, especially when compared to symptoms of flu. Serious reactions are rare, and flu vaccines are given safely to millions of people every year. People who think that they have been injured by a flu vaccine should contact their healthcare provider and seek medical care; they can also file a report with the Vaccine Adverse Event Reporting System (VAERS) FACT: People can get a flu vaccine and COVID-19 vaccine at the same visit if they are eligible, and if the timing for each vaccine is right. Studies support the safety of getting a flu vaccine and COVID-19 vaccine at the same visit. VCHCP strongly recommends its members receive a flu vaccine annually unless your doctor has instructed you not to have the vaccine due to your medical condition(s). The Flu Facts provided are from the Centers for Disease Control and Prevention website and present the information related to obtaining a flu vaccine. The Ventura County Health Care Agency offers several options on where to obtain your vaccine such as Ventura County Health Care Agency Ambulatory Care Clinics, Ventura County Public Health Immunization Program at Community Clinics and at Community Events. To receive your flu vaccine, visit your primary care physician. Other resources include Ventura County Public Health at hca.venturacounty.gov/public-health/diseases-and-conditions/flu/
Sources: Centers for Disease Control and Prevention. About Influenza (02/26/2026). cdc.gov/flu/about/. Ventura County Public Health. Influenza (2024). hca.venturacounty.gov/public-health/diseases-and-conditions/flu.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
FAQs FAQs
FOR MEMBERS ABOUT SPECIALTY MEDICATIONS It is very important that you remain ➠ proactive in following up with your specialty medication. This will minimize the delay in getting timely medications. What is a “Specialty Medication”? Specialty Medications are high-cost medications, regardless of how they are administered (injectable, oral, transdermal, or inhalant), and are often used to treat complex clinical conditions that require close management by a physician due to their potential side effects and the need for frequent dosage adjustments.
What if my Doctor prescribes a “Specialty Medication” for me? Most “Specialty Medications” require prior authorization from the Plan. Your doctor will need to complete a Prescription Drug Prior Authorization Request form and submit it to the Health Plan for approval.
How do I know if my medication is a “Specialty Medication”?
How do I get my specialty medication? Once the Health Plan approves your doctor’s Treatment Authorization Request, Accredo verifies the approval and contacts the patient to coordinate shipment of the medication to the patient’s address within 24 to 48 hours. Accredo cannot ship your medication without speaking with you directly to arrange shipment. If you receive a message from Accredo, you will need to call Accredo back. Accredo will also provide any equipment necessary for you to take your medication. You can call Accredo directly with any questions at (800) 803-2523.
What if I need to start taking my medicine right away? If your doctor determines that it is medically necessary for you to begin taking the medication right away, he/ she can write a prescription for a
Contact Accredo at (800) 803-2523. Accredo is Express Scripts’ specialty pharmacy provider.
one-time, 30-day supply to be filled at a local
How much will my specialty medication cost?
What if my medication hasn’t arrived yet?
You can look up your out-of-pocket cost for any medication (whether specialty or not) by going to the Express Scripts website at express-scripts.com and creating an online account. Or you can call Express Scripts directly at (800) 811-0293 to find out your out-of-pocket cost for a particular medication or for help logging into their website.
pharmacy upon approval by the Plan.
If you are concerned about the amount of time it is taking for your medication to be shipped to you, or if you have any other questions or concerns, please call the Plan’s Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 Monday through Friday between the hours of 8:30 am and 4:30 pm.
For more information about the Plan’s Specialty Medication policies or Prescription Medication Benefit Program please see the Plan’s website at vchcp.venturacounty.gov/prior-authorization-drug-guidelines or call the Plan’s Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 between the hours of 8:30 am and 4:30 pm Monday-Friday. Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
33
COMBATING RESPIRATORY INFECTIONS:
TAKING THE RIGHT STEPS FOR
We care about your health and want to ensure you receive the most appropriate care for respiratory infections like acute bronchitis and bronchiolitis. Did you know that antibiotics are not always the best solution for these conditions? In fact, using antibiotics when they are not needed can lead to antibiotic resistance and potential side effects. According to the Centers for Disease Control and Prevention (CDC), most cases of acute bronchitis and bronchiolitis are caused by viruses, not bacteria, making antibiotics ineffective.
When it comes to upper respiratory infections (URIs), receiving
THE POWER OF ANTIBIOTIC AWARENESS
Our goal is to improve your care and avoid unnecessary antibiotic use. So, if you or a loved one experience symptoms like coughing, chest congestion, or mild difficulty breathing, don’t rush for antibiotics. Instead, reach out to your healthcare provider. They can help determine the best course of action for your specific case, which
the appropriate treatment is essential for your health and well-being. URIs, such as the common cold and flu, are usually caused by viruses and do not require antibiotics. Did you know that taking antibiotics when they are not needed can lead to antibiotic resistance and potential side effects? At Ventura County Health Care Plan, we are committed to providing you with the best care possible. If you or your family members experience symptoms like a runny nose, sore throat, or cough, it’s important to consult with your healthcare provider. They can assess your condition and recommend the most suitable course of action, which may include rest, hydration, and over-the-counter medications for symptom relief.
may include rest, fluids, and other supportive measures.
Remember, antibiotics are powerful medications that should only be
Let’s work together to combat respiratory infections wisely, preserving antibiotics for when they are truly needed.
used when necessary to treat bacterial infections. By working together
By doing so, we can protect ourselves and future generations from the threat of antibiotic resistance.
References: Centers for Disease Control and Prevention (CDC). (2025). Chest Cold (Acute Bronchitis) Basics:
cdc.gov/acute-bronchitis/about National Institute for Health and Care Excellence (NICE). (2021).
34
UPPER RESPIRATORY INFECTIONS
and avoiding unnecessary antibiotic use, we can protect ourselves and preserve the effectiveness of antibiotics for future generations.
Let’s take the right steps for upper respiratory infections and prioritize your health and well-being. References: Centers for Disease Control and Prevention (CDC). (2026). About Common Cold.
cdc.gov/common-cold/about
Bronchiolitis in Children. Diagnosis and Management:
Centers for Disease Control and Prevention (CDC). (2026). Manage
nice.org.uk/guidance/ng9
Common Cold. cdc.gov/common-cold/treatment
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Flu Vaccine
Influenza is a contagious illness caused by the flu virus. The flu can cause mild to severe illness, and at times can lead to death. That is why it is recommended that everyone 6 months and older get a flu vaccine every year (unless told otherwise by your physician). Flu vaccines will provide protection against three (trivalent vaccine) or four (quadrivalent vaccine) flu viruses and will be available in the fall throughout Ventura County at pharmacies, grocery stores, and other locations. The best way in protecting yourself against the flu virus is getting the flu vaccine each year. It can be taken simultaneously with other vaccines, including COVID-19. Members 65 years of age or older are encouraged to get a high dose quadrivalent flu shot by the Ventura County Public Health. The high dose vaccine has four times the amount of potency and is recommended for seniors with a lower immune response to vaccination and are at a particular risk for experiencing significant and negative outcomes from a flu infection. The Ventura County Health Care Agency offers several options on where to obtain your vaccine such as Ventura County Health Care Agency Ambulatory Care Clinics, Ventura County Public Health Immunization Program at Community Clinics and at Community Events.
Common symptoms of the flu are: • • • • • •
• Headaches Fever • Fatigue Chills • Some people may Cough have vomiting and Sore throat diarrhea, more Runny or stuffy nose common in children Muscle or body aches than adults
To receive your flu vaccine, visit your primary care physician. Other resources include Ventura County Public Health at hca.venturacounty.gov/public-health/ diseases-and-conditions/flu/.
References: Centers for Disease Control and Prevention. About Influenza (2026). cdc.gov/flu/about/ Ventura County Public Health. Influenza (2025). hca.venturacounty.gov/public-health/ diseases-and-conditions/flu
THROAT INFECTIONS:
CHOOSING WISELY FOR YOUR HEALTH When you or your loved ones experience a sore throat, it’s essential to seek the right care to ensure a swift and accurate diagnosis. Pharyngitis, commonly known as a sore throat, can have various causes, including viral and bacterial infections.
Did you know that not all sore throats require antibiotics? According to leading healthcare organizations like the American Academy of Family Physicians (AAFP) and the Centers for Disease Control and Prevention (CDC), most sore throats are caused by viruses, and antibiotics won’t help in these cases. Inappropriately prescribed antibiotics can lead to antibiotic resistance and potential side effects. Our focus is on providing you with the best care possible, which means making informed decisions about when antibiotics are necessary. If you or your loved ones have a sore throat, we encourage you to consult with your healthcare provider. They will conduct appropriate testing,
like a rapid strep test, to determine if your sore throat is caused by bacteria. If it’s viral, your provider will recommend supportive care to help manage your symptoms. Together, let’s choose wisely for your health and ensure that antibiotics are reserved for situations where they are most effective. By doing so, we protect ourselves, our community, and the effectiveness of these essential medications.
References: American Academy of Family Physicians (AAFP). (2024). Sore Throat.
familydoctor.org/condition/sore-throat Centers for Disease Control and Prevention (CDC). (2025). Clinical Guidance for Group A Streptococcal Pharyngitis.
cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
35
EVERYONE DESERVES TO HAVE A
HEALTHY, SMOKEFREE HOME! DID YOU KNOW? People living in apartments are more likely to be exposed to secondhand smoke.1 » Smoke can enter your home through vents, electrical outlets, windows, and even tiny cracks in walls.
ANY AMOUNT OF SECONDHAND SMOKE CAN BE HARMFUL » 41,000 nonsmokers die from secondhand smoke each year in the U.S. 3
65%
Up to 65% of the air in an apartment can come from other units in the building. 2
It is especially dangerous for children and can cause permanent damage to growing lungs.4
YOUR LUNGS CAN’T TELL THE DIFFERENCE » Marijuana secondhand smoke is harmful just like cigarette smoke.5 It has many of the same toxic chemicals that cause cancer and other diseases. » Vaping produces tiny droplets of harmful chemicals, including lead. It’s NOT just harmless water vapor! 5
36
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
YOU CAN MAKE A DIFFERENCE! TO FULLY PROTECT YOUR HOME FROM SECONDHAND SMOKE, YOUR ENTIRE APARTMENT COMPLEX NEEDS TO BE SMOKEFREE This includes: » Inside units » On patios and balconies » Outdoor common areas such as pools, parking lots, stairways, and courtyards.
» Apartment owners have the legal authority to make their property entirely smokefree. Contact your local health department for resources to offer managers and landlords about the benefits of a smokefree property. » Share information with neighbors about the harms of all forms of secondhand smoke. Try posting information on bulletin boards or in laundry rooms. » Reach out to city officials about local laws that would require apartments and other multi-unit housing to be smokefree. » Check the strength of your city’s smokefree policies and take action at www.undo.org/secondhand-dangers
For free and confidential help quitting tobacco and nicotine. Kick it California Visit kickitca.org Call 1-800-300-8086 Text “Quit Smoking” or “Quit Vaping” to 66819 Download the free Kick It: Quit Smoking | Vaping mobile app
Contact: (805) 201-STOP (7867) Callitquits@Venturacounty.gov
REFERENCES: 1. Tsai, J., et al. (2018). Exposure to Secondhand Smoke Among Nonsmokers - United States, 1988-2014. Morbidity and Mortality Weekly Report, 67(48), 1342–1346. 2. Center for Energy and Environment. (2004). Reduction of Environmental Tobacco Smoke Transfer in Minnesota Multifamily Buildings Using Air Sealing and Ventilation Treatments. 3. U.S. Department of Health and Human Services. (2014). The health consequences of smoking – 50 years of progress: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 4. Graves, BM, et al. (2020). Comprehensive characterization of mainstream marijuana and tobacco smoke. Scientific Reports, 10(1), 7160. https://doi.org/10.1038/s41598-020-63120-6 5. National Academies of Sciences, Engineering, and Medicine. (2018). Public Health Consequences of E-Cigarettes. © Revised 2025. California Department of Public Health. Funded under contract # 21-10001. J999.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
37
MEMBER SATISFACTION WITH
SU RV E Y RESULT S
Utilization Management A s part of our continuing commitment to serve our members, VCHCP conducted a 2025 Consumer Assessment of Healthcare Providers and System (CAHPS) survey. The purpose of this survey is to measure how well the Health Plan meets members’ expectations and goals. SPH Analytics was selected by VCHCP to randomly select eligible members to participate in the survey using a combination of mail and telephone outreach. We would like to thank the 132 members who responded to our survey, yielding a 12.0% response rate. Based on your responses, specifically with regards to your “experience with our Utilization Management” (UM), the Plan is committed to improving member survey results and experiences. The specific questions in the survey that pertain to your experience with our Utilization Management are:
Q9: IN THE LAST 12 MONTHS, how
often was it easy to get the care, tests, or treatment you needed?
Q20: IN THE LAST 12 MONTHS, how
often did you get an appointment to see a specialist as soon as you needed?
We heard your feedback and recognized we have opportunities for improvement. We have continued these actions to improve your experience with our Utilization Management such as: Telemedicine (Teladoc) which helped with access issues. Direct Specialty Referral Program for our VCHCP health plan members. The Primary Care Physicians can directly refer members to certain in network/contracted specialty providers without requiring prior authorization.
Evaluating and removing prior authorization requirement on services that the Plan generally approve, reducing the barrier of having to obtain prior authorization. The intent is to make it easy for members to get these services. 38
Member Newsletter
Working with its contracted providers to send timely referrals to the Plan to ensure timely processing of prior authorization requests. Continuing efficiencies in prior authorization processing. Electronic prior authorization referral process at the Ventura County Medical Center (VCMC) through the Cerner system. Addressing access issues for continued improvement with collaboration between the Plan and providers. Executing contracts with needed specialists in geographic areas of need.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Monitoring the timeliness of our UM prior authorization processing daily to ensure timely review and compliance with regulatory requirements. In 2025, over 87% of requests received have been completed within the specified regulatory requirement. Your continued participation in our annual member satisfaction surveys and other feedback will help us identify areas of opportunity for improvement, which in turn aids us in increasing the quality of care you receive. Thank you again for your participation.
HAVE YOUR SAY ABOUT YOUR EXPERIENCE WITH
DISEASE MANAGEMENT & CASE MANAGEMENT
All VCHCP members who are in our Disease Management or Case Management Programs will receive a survey to evaluate the program they are enrolled in. These surveys measure how useful our programs are to the members, and evaluate where we need to improve. Programs being surveyed include, Diabetes Disease Management, Asthma Disease Management, and Autism Case Management.When you receive the survey, simply complete the questions and return it in the pre-paid envelope. Your responses are completely anonymous. Thank you in advance for helping us evaluate our programs, making them even better! If you have questions regarding surveys or any of our Disease Management or Case Management programs, call Utilization Management at (805) 981-5060.
If you have any questions or need to reach an Express Scripts Representative, please call (800) 811-0293. The Ventura County Health Care Plan provides pharmacy coverage through Express Scripts. Members can create an online Express Scripts profile account at express-scripts.com or you may also access Express Scripts by visiting the Plan’s website on the Member page at vchcp.venturacounty.gov/pharmacy, scroll down, and click on express-scripts.com. Members have access to the following services and information once their profile is established. • Manage Prescriptions – Refill/Renew • Determine Financial Responsibility for a Drug • View Recent Orders & Status
• View Prescription History – Ability to Search by RX Number • View Health and Benefit Information
Standing REFERRALS A standing referral allows members to see a specialist or obtain ancillary services, such as lab, without needing new referrals from their primary care physician for each visit. Members may request a standing referral for a chronic condition requiring stabilized care. The member’s primary care physician will decide when the request meets the following guidelines.
is anticipated that the care will be ongoing:
A standing referral may be authorized for the following conditions when it
• Allergy injections • Defibrillator checks
• Chronic health condition (such as diabetes, COPD etc.) • Life-threatening mental or physical condition
• Pregnancy beyond the first trimester • Degenerative disease or disability • Radiation treatment • Chemotherapy
• View Account Information • Find the location of an in-network Pharmacy – Ability to Search by Zip-code • Pacemaker checks • Dialysis/end-stage renal disease • Other serious conditions that require treatment by a specialist A standing referral is limited to 6 months, but can be reviewed for medical necessity as needed, to cover the duration of the condition. If you change primary care physicians or clinics, you will need to discuss your standing referral with your new physician. Changing your primary care physician or clinic may require a change to the specialist to whom your
primary care physician makes referrals.
Additional information regarding Standing Referrals is located on our website: vchcp.venturacounty.gov/ StandingReferralsToSpecialists or by calling Member Services at (805) 981-5050 or (800) 600-8247.
2026 NATIONAL PREFERRED FORMULARY EXCLUSIONS The excluded medications are not covered by the National Preferred Formulary beginning January 1, 2026, unless otherwise noted. Please note that members filling prescriptions for one of these excluded drugs may pay the full retail price. Please discuss any alternative preferred medications with your doctor. To access the list of National Preferred Formulary Exclusions, please visit our website at
vchcp.venturacounty.gov/nationalpreferredformularyexclusions-3 Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
39
Why Metabolic Testing Matters
For children and teens taking antipsychotic medication If your child is taking an antipsychotic medicine, metabolic testing is an important part of their care. These tests help your child’s healthcare provider make sure the medicine is working safely and that your child stays healthy.
Why does my child need these tests? These tests can help find health problems early, before they become more serious. Experts recommend testing: • Before starting antipsychotic medicine • During treatment • At least once a year
What do the tests check for? Regular testing can help your child’s healthcare provider watch for: • Weight gain • High blood sugar, which can lead to diabetes • High cholesterol or other unhealthy blood fat levels • Changes in hormone levels • Muscle stiffness, shaking, or other movement problems • Changes in heart health
How do these tests help? Regular testing helps your child’s healthcare provider: • Check your child’s overall health • Watch for side effects from the medicine • Make changes to treatment if needed • Help your child stay as healthy as possible while taking their medicine
Talk with your child’s healthcare provider If your child is taking an antipsychotic medicine, ask when they should have their next health check or blood test. Keeping up with regular testing is an important part of your child’s care.
Source: Optum. (2025). Metabolic testing recommendations for children and adolescents with severe mental illness and/or on antipsychotics [Flyer]. providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/pcp-tool-kit/ scrnChldAdolAntipsy.pdf 40
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Follow-Up Care for Children and Teens After Starting ADHD Medicine If your child has started medicine for ADHD, follow-up visits are an important part of their care. These visits help your child’s healthcare provider make sure the medicine is working well and is not causing problems.
When should my child come back? Your child should have: • A follow-up visit within 2 weeks after starting ADHD medicine. • Another visit within 30 days of the first prescription. • At least 2 more follow-up visits during the next 9 months. Your child’s healthcare provider may want to see them more often if needed.
Why are follow-up visits important? At these visits, your child’s healthcare provider will: • Check if the medicine is helping. • Ask about side effects. • Make sure your child is taking the medicine as directed. • Answer your questions. • Change the dose or medicine if needed.
How can I help? You can help by: • Scheduling the next visit before you leave the office. • Writing down any changes you notice, such as: o Better focus o Changes in sleep o Changes in appetite o Mood changes o Any side effects • Bringing your notes to each visit. • If your provider asks, check your child’s blood pressure or weight at home and share the results. • Asking if a virtual visit is an option for your family.
Medicine is only one part of treatment Medicine can help many children with ADHD. Behavioral therapy can also help. Using both together may improve attention, reduce impulsive behavior, and help your child build skills for home and school. Keeping your child’s follow-up visits helps make sure they get the care they need and that their treatment stays on track.
Source: Optum. (2025). Follow-up care recommendations for children and adolescents prescribed ADHD medications [Flyer]. public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/pcp-tool-kit/4419-fuADHD-MedsScribed.pdf Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
41
Psychosocial Care for Children and Teens For many children and teens with mental health conditions that do not include psychosis, experts recommend starting with psychosocial care before trying antipsychotic medicine. Psychosocial care helps children learn healthy ways to manage their thoughts, feelings, and behaviors. It can also give families the support they need.
Types of psychosocial care Your child’s healthcare provider may recommend: • Counseling or therapy, including individual, family, or group therapy • Crisis support during a mental health emergency • Peer support, where children or teens connect with others who have similar experiences • Activity therapy, such as music, art, or play therapy
What about medicine? Sometimes, a child may need medicine as part of their treatment. Before prescribing an antipsychotic medicine, healthcare providers carefully consider the benefits and the possible risks. Antipsychotic medicines can cause side effects, including: • Weight gain • High blood sugar or high cholesterol • Changes in hormone levels • Muscle stiffness, shaking, or other movement problems • Changes in heart health Your child’s healthcare provider will talk with you about these risks and monitor your child if medicine is needed.
Working together Every child is different. Talk with your child’s healthcare provider about the best treatment plan for your child. Starting with psychosocial care can help many children and teens build skills, improve their mental health, and support their overall well-being.
Source:
Optum. (2025). Psychosocial care is recommended as first-line treatment for children and adolescents with non-psychotic conditions [Flyer]. public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/cqiTools/ampAPP2288.pdf
42
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Wellness Programs Ventura County Health Care Plan provides support and information to promote healthy living for our members. To assist in meeting your wellness goals, VCHCP has identified self-management tools for members to use. The links below connect to tools and resources to help you live well and take care of yourself. We encourage you to take advantage of these tools to help set and work toward your health and wellness goals. If you have any questions, please contact Jennylyn Regacho, QA nurse at (805) 981-5391. FACTOR 1. HEALTHY WEIGHT (BMI) MAINTENANCE - MAINTAINING A HEALTHY WEIGHT Adult:
cdc.gov/bmi/adult-calculator/
Child/Teen BMI:
cdc.gov/bmi/child-teen-calculator
Learn more about Healthy Weight, Nutrition, and Physical Activity:
cdc.gov/healthy-weight-growth/about
FACTOR 2. SMOKING AND TOBACCO USE CESSATION Quiz: How Strong is Your Nicotine Addiction?
smokefree.gov/challenges-when-quitting/withdrawal/nicotineaddiction-quiz
Quitting Starts Now. Make Your Quit Plan
smokefree.gov/build-your-quit-plan
FACTOR 3. ENCOURAGING PHYSICAL ACTIVITY Exercise Activity Calculator
cancer.org/cancer/risk-prevention/diet-physical-activity/getactive/exercise-counts-calculator.html
How much physical activity do adults need? cdc.gov/physical-activity-basics/guidelines/adults.html
FACTOR 4. HEALTHY EATING Nutrition and Activity Quiz
cancer.org/cancer/risk-prevention/diet-physical-activity/ nutrition-activity-quiz.html
Calorie Counter
cancer.org/cancer/risk-prevention/diet-physical-activity/eat-healthy/ calorie-counter-calculator.html
Healthy Eating for a Healthy Weight
cdc.gov/healthy-weight-growth/healthy-eating FACTOR 5. MANAGING STRESS
FACTOR 6. AVOIDING AT-RISK DRINKING.
Anxiety Test
Alcohol Use Screening Tool
Coping with Stress
Alcohol Use and Your Health
screening.mhanational.org/screening-tools/anxiety/?ref cdc.gov/mental-health/living-with
cdc.gov/alcohol/checkyourdrinking/index.html cdc.gov/alcohol/about-alcohol-use
FACTOR 7. IDENTIFYING DEPRESSIVE SYMPTOMS Depression Test
screening.mhanational.org/screening-tools/depression Online Mental Check-up
healthymindsphilly.org/screening/
Mental Health Conditions: Depression and Anxiety
cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
43
Formulary Web Posting Ventura County Health Care Plan updates the formulary with changes on a monthly basis and re-posts monthly on VCHCP’s member and provider website. The formulary includes information on covered pharmaceuticals and pharmaceutical management
procedures
including
co-pay-
ments, prior authorization, drug limits, generic substitution, therapeutic interchange, and step-therapy. Please refer to the Formulary Drug List by clicking this link:
vchcp.venturacounty.gov/ ProviderDrugList
To access the policy and procedure for the Drug benefit Program of VCHCP, please click this link vchcp.venturacounty.gov/ prescriptionmedicationbenefitprogramdescription-2
44
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Pharmacy Updates A list of additions and deletions for the Ventura County Health Care Plan’s formulary was recently approved by the Plan’s Pharmacy & Therapeutics Committee and can be found by visiting the Plan’s website at vchcp.venturacounty.gov/Provider-Notification-Adds-and-Deletes. Additional information regarding the National Preferred Formulary is available through Express Scripts (ESI) express-scripts.com. Logging in is required. • Plan’s Drug Policies vchcp.venturacounty.gov/ prior-authorization-drug-guidelines • Step Therapy vchcp.venturacounty.gov/ StepTherapyCheatSheet • Drug Quantity Limit o vchcp.venturacounty.gov/DQM-Advantage o vchcp.venturacounty.gov/ DQM-Advantage-Plus o vchcp.venturacounty.gov/DQM-Limited • Preferred Medications List vchcp.venturacounty.gov/ProviderDrugList • National Preferred Formulary vchcp.venturacounty.gov/ NationalPreferredFormulary
A member or a member’s designee can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization, by submitting an exception via online request available in the VCHCP member website (vchcp.venturacounty.gov/request-for-pharmacy-formulary-exception) or by calling the Plan at (805) 981-5060.
HOW TO REQUEST a Step Therapy Exception, Formulary Exception and Prior Authorization Exception Submitting Exception Requests To The Preferred Drug List Members can request individual exceptions to the preferred drug list through their primary care practitioner or directly to VCHCP by phone or through the VCHCP website.
VCHCP will review your exception request and will either contact you or reach out to your doctor to get more clinical information. To submit an exception request, you may complete the online request form available on VCHCP’s website at vchcp.venturacounty.gov/request-for-pharmacy-formulary-exception, or by contacting the Plan directly at (805) 981-5050. A Prior Authorization (PA) request can be submitted by the practitioner on the member’s behalf to VCHCP for consideration. Practitioners themselves may also initiate a petition for consideration of coverage. Practitioners themselves may should include relevant clinical history, previous medications prescribed and tried, contraindications or allergies to medications and any other contributory information deemed useful. VCHCP will review the information according to the PA policy. Because the PA requests are reviewed by the Plan and not the PBM, if the medication does not meet criteria on initial review by the nurse reviewer, it is reviewed by a physician reviewer and special consideration is given to the exception request based on the information received. The physician reviewers are also available by phone to discuss an exception request with the practitioner.
Population Health Management Programs Ventura County Health Care Plan provides ongoing support of our members to meet their healthcare needs. Our goal is to empower you to take control of your health. VCHCP wants to be sure you are aware of the many programs, services, and activities offered by us to support you in your health care goals. Please visit our website at vchcp.venturacounty.gov/VCHCPPopulationHealthManagement to see the list of programs/services offered, how you are eligible to participate, and how you decide to participate. If you need further information or have any questions regarding the programs or activities offered, please contact our Health Services Department at (805) 981-5060 or toll-free (800) 600-8247. Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
45
EMERGENCY ROOM VS URGENT CARE HOW SHOULD I CHOOSE?
EMERGENCY ROOM VISIT
Copays and Follow Up No one likes Emergency Room (ER) visits, nor how pricey they can become.
Avoid having to pay multiple ER copays by ensuring that you see your Primary Care Provider (PCP) for any follow-up care. Just a reminder... Additional ER copays will be applied when returning for follow-up care at the ER. A sudden trip to the ER can be difficult and often results in a change in medication or treatment. After a visit to the ER, it is very important that you make an appointment to see your PCP and/or specialist when applicable, as soon as possible, or within 30 days. If you find that making an appointment with your PCP or specialist after an ER visit is difficult and you can’t be seen within 30 days, or if your ER visit was due to your inability to be seen by your PCP, please notify your Ventura County Health Care Plan Member Services Department at (805) 981-5050. Your ability to access health care is important to us. 46
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
ANTI-DEPRESSANT
Medication Management M
embers who are diagnosed with depression and prescribed medication should work closely with their physician to ensure proper treatment. To achieve maximum results from anti-depressant medication, it is important to remain on the medication consistently for at least 6 months, or for the duration prescribed by your physician. VCHCP contracts with Express Scripts for prescription medications.
If you are seeing a primary care physician (PCP), be sure that your PCP is collaborating care with any of your other providers, especially your mental health specialist. Communication is the key for your overall health care. For more information, please visit the VCHCP website at vchcp.venturacounty.gov/ClinicianBrochure.
If you have any questions about the services you may need, please contact your physician.
Depression is a chronic disease that requires long-term management, typically with medication.
In addition, for Behavioral Health services that you may need, please contact OptumHealth Behavioral Solutions of California at (800) 851-7407 or visit the website at liveandworkwell.com/en/public.
Care for Individuals
Diagnosed with Schizophrenia and/or Prescribed Antipsychotic Medication Regular care is crucial for individuals with schizophrenia or those prescribed antipsychotic medications. Here’s wahat you can do: ✓ Health Monitoring: Get metabolic/lipid tests annually, including HbA1c or blood glucose and LDL-C or cholesterol levels.
✓ Seeking Support: Utilize resources like liveandworkwell.com for patient education and mental health provider information.
✓ Medication Adherence: Stay on track with your prescribed medications. Educate yourself, be patient, and communicate openly with your healthcare provider.
✓ Coordinate Care: Share contact information with your treating providers to ensure comprehensive care.
We’re here to support your mental health journey. References: - Optum, Inc. All Rights Reserved. BH4885 06/2023 - Recommendations based on the National Committee for Quality Assurance HEDIS® specifications
DEPRESSION EDUCATION MATERIALS AVAILABLE Depression is a common mental illness that can be very limiting. When members are well informed and seek treatment, they can successfully work through life problems, identify coping skills, and retain a sense of control. VCHCP has created a brochure of depression information and resources available to members. This valuable resource is available on
the VCHCP website at vchcp.venturacounty. gov/ClinicianBrochure. If you do not have access to the website or would like further information, please call (805) 981-5060 and ask to speak with a Disease Management Nurse.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
47
The Importance of Well Child Visits
Keep Your Child Healthy: Don’t Skip Well-Child Visits! When your child is sick, seeing the pediatrician is important to treat the problem and help them feel better. But sick visits do not replace regular well-child checkups. Both types of visits serve different purposes and are essential for your child’s health. Well-child visits focus on preven-
tion, growth, and long-term health.
What Happens at a Well-Child Visit? • Measure growth: height, weight, head size • Check developmental milestones: speech, movement, social skills • Give vaccines and preventive care • Screen for vision, hearing, behavior, and emotional well-being • Answer parent questions and provide guidance for healthy habits Well-child visits are also a great time for parents to ask questions and get guidance on nutrition, sleep, safety, behavior, and school readiness—topics often not fully addressed during sick visits.
Recommended Well-Child Visit Schedule: • Newborn: within 2 weeks of birth • Infants: 2, 4, 6, 9 months • Toddlers: 1 year, 15 months, 18 months • Children: 2–10 years, annually • Adolescents: yearly until age 21 Remember:
Sick Visits vs. Well-Child Visits • Sick visits: Treat specific illnesses, like fever, cough, or ear infections. • Well-child visits: Track growth and development, give vaccines, perform screenings, and provide preventive care.
Why Well-Child Visits Matter Childhood is a time of rapid growth and change. Regular well-child visits help ensure your child is growing, developing, and staying healthy. These visits allow your pediatrician to catch potential problems early, provide preventive care, and support your child’s overall well-being. 48
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Even if your child has been seen recently for a sick visit, keeping up with scheduled well-child visits ensures nothing is missed. Both types of visits work together to keep your child healthy, growing, and thriving. They help catch problems early, keep vaccines on schedule, and give you guidance to help your child thrive. Your pediatrician knows your child’s medical needs best— regular visits help them stay ahead of any concerns. Schedule your child’s next well-child visit today! You may also find information on the Plan’s website under Preventive Health Guidelines 2025-2026 at vchcp. venturacounty.gov/wp-content/uploads/2023/03/ preventiveHealthGuidelinesCommercial.pdf#page=2
WHAT IS MDD? FAR MORE THAN JUST FEELING SAD Major depressive disorder (MDD), also known as major depression, unipolar depression, or clinical depression, is a common, serious, and treatable mental health condition. It is more than feeling sad or going through a rough patch and can cause severe symptoms that change the way a person thinks, feels, and acts. It has been estimated that 21 million adults (8.4% of the population) in the U.S. had depression in 2020. The word “depression” can be used to mean low mood seen in a wide range of different situations and health conditions. Here, we will use “depression” to refer to MDD. Depression is different for everyone. It can be a feeling of sadness that does not go away. People can stop wanting to do things they used to enjoy. Depression can involve changes in mood or behavior such as increased anger or irritability, becoming withdrawn, negative, or
isolated, engaging in more high-risk activities, increasing use of alcohol or other drugs, problems with sexual desire or performance. For some, symptoms appear as physical problems like aches, pains, stomach upset, or chest tightening. Depression can affect many parts of daily life — work or study, relationships, and home life. Left untreated, depression can last months or years and can be devastating for people who have it and those who care for them. With early detection, diagnosis, and treatment, many people will get better. Sometimes people feel that they should be able to solve their own problems, or that nothing will help. Depression can make people think this way. If you are concerned that you or someone you care about might have depression, talk to a trusted healthcare professional, or reach out to a friend or family member, or a support group or helpline.
Studies have shown that patient outcomes improve when primary care providers, case managers, and mental health specialists collaborate to screen for depression, monitor symptoms, provide treatment, and refer patients to specialty care as necessary. For additional educational materials, Optum Live and Work Well site, has related articles on Depression. Please check the following link: liveandworkwell.com/en/public/prevention/depression/overview Sources: The Basics of MDD. 2024. Retrieved 06/26/2026, from MDD.CARE, mdd.care/patient/the-basics-of-mdd/what-is-mdd-far-more-than-just-feeling-sad Why are Follow-Up Visits Important? Retrieved 06/26/2026, from MDD.CARE, mdd.care/patient/navigating-your-mdd-experience/why-are-follow-up-visits-important Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
49
VENTURA COUNTY HEALTH CARE PLAN CONTRACTS WITH
OptumHealth Behavioral Solutions FOR MENTAL/BEHAVIORAL HEALTH AND SUBSTANCE USE SERVICES Optum’s Live and Work Well website is packed with valuable information for healthy living. For easy access to this information, look for the Optum logo on the VCHCP website – click on it and you are on your way to learning more about healthy living! You can also access it through Behavioral Health, EAP, WorkLife & Mental Health Services | Live and Work Well.
Following are two examples of articles available for members to help with common behavioral health issues.
Attention Deficit Hyperactivity Disorder (ADHD)
Autism
What is attention deficit hyperactivity disorder?
What is Autism?
Attention deficit hyperactivity disorder (ADHD) is a condition in which a person has trouble paying attention and focusing on tasks, tends to act without thinking, and has trouble sitting still. It may begin in early childhood and can continue into adulthood. Without treatment, ADHD can cause problems at home, at school, at work, and with relationships. In the past, ADHD was called attention deficit disorder (ADD).
Autism is a developmental disorder. The disorder makes it hard to understand the world. Communication is especially challenging. It is hard for people with autism to attach meaning to words and facial expressions. Individuals with the disorder have trouble interacting with others. People with autism may engage in repetitive or obsessive behaviors and, in some cases, harmful behaviors, such as hitting their heads against a wall or repeatedly pinching themselves.
What causes ADHD? The exact cause is not clear, but ADHD tends to run in families.
What are the symptoms? The three types of ADHD symptoms include:
• Trouble paying attention. People with ADHD are easily
distracted. They have a hard time focusing on any one task.
• Trouble sitting still for even a short time. This is called
hyperactivity. Children with ADHD may squirm, fidget, or run around at the wrong times. Teens and adults often feel restless and fidgety. They aren’t able to enjoy reading or other quiet activities.
• Acting before thinking. People with ADHD may talk too loud,
laugh too loud, or become angrier than the situation calls for. Children may not be able to wait for their turn or to share. This makes it hard for them to play with other children. Teens and adults may make quick decisions that have a long-term impact on their lives. They may spend too much money or change jobs often.
How does ADHD affect adults? Many adults don’t realize that they have ADHD until their children are diagnosed. Then they begin to notice their own symptoms. Adults with ADHD may find it hard to focus, organize, and finish tasks. They often forget things. But they also often are very creative and curious. They love to ask questions and keep learning. Some adults with ADHD learn to manage their lives and find careers that let them use those strengths. 50
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
What are the Symptoms? Autism is usually noticed in the first three years. Sometimes the symptoms are apparent when comparing the development of your child to others their age. Other times the symptoms may come on all at once. Some signs to look for are:
Communication symptoms:
• Talks late or not at all; speaks loudly or with flat tones
• Points or uses other motions to indicate needs
• Repeats words or phrases without understanding the meaning
• May talk at length about something even if no one is listening
Autism CONTINUED
Autism Screening FOR ALL CHILDREN
Social interaction symptoms: • Likes to be alone • Dislikes being held or touched • Does not know how to interact; poor listener
• May stare at something for a long time, ignoring the rest of the world
• Poor eye contact • Does not understand the feelings of others
Behavior symptoms:
• Likes routine; is upset by change • Does not pretend or use his or her imagination
• May have tantrums or show aggression • May become very attached • May engage in repetitive movements like rocking
• May bang his or her head or hurt self • May be sensitive to noises that others tolerate
• May have an unusual reaction to the way things smell, taste, look, feel or sound
Autism Spectrum Disorder (ASD) is the name for a group of developmental disorders. Studies show that when children with ASD are diagnosed early and receive early intervention, they have improved long-term outcomes. With this in mind, VCHCP has in place a Screening for Autism Policy that all Family Practitioners and Pediatricians caring for children age 2 and younger are to follow. Your child’s provider will administer a standardized screening and surveillance of risk factors at age 18 and 24 months. Your provider will also perform a general observation at every well-child visit. Please understand that these screenings are to be provided for all children at age 18 and 24 months. If you have concerns about the screening or the results, contact your child’s provider.
If you have any questions about the Autism Screening Policy, please contact VCHCP Utilization Management department at (805) 981-5060.
Autism Spectrum DISORDERS
Members now have an opportunity to seek assistance for Autism
Spectrum Disorders (ASD). VCHCP
recommends all members with ASD or
REQUEST
Case Management or Disease Management
parents of children with ASD participate in our Autism Case Management
Not everyone experiences autism in the same way. Some may have severe trouble with some things and not be as challenged by others. If you suspect that your child may have autism, trust your instincts. Take your child to a doctor and have them examined.
Program.
Additionally, VCHCP has a Case Management Program specific to the needs of those with Autism. Contact the VCHCP Case Management Department for more information at (805) 981-5060 or submit a request online by visiting VCHCP’s website here: vchcp.venturacounty.gov/request-casemanagement-or-disease-management.
call you within 2 business days.
Visit vchcp.venturacounty.gov/request-case-management-or-disease-
management to request Case Management or Disease Management.
You will be prompted to enter member specific information. You will then
submit this form to a secure email. A nurse will evaluate your request and
If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
51
DOULAS A Doula is a trained and certified professional who can provide support before, during and after delivery. They do not deliver the member’s baby, but instead complement the care they will receive from their healthcare team. Having a doula may provide a great experience during a major milestone in their lives. According to the American Pregnancy Association Doulas provide emotional, physical and educational support to a mother who is expecting, is experiencing labor or has recently given birth. The purpose of having a Doula is to help empower women to have a safe, memorable and empowering birth experience.
Types of Doulas:
Birth Doula Sometimes called birth companions or labor doulas. They prepare you for childbirth and ongoing support during labor.
Doulas typically meet with women and their partner every few months throughout their pregnancy to build rapport and discuss their goals of birth. This can be beneficial to women who have limited support system and who might otherwise be alone during the later stage of their pregnancy and childbirth. Doulas serve as your advocate and can help facilitate a positive and safe birthing experience. entura County Health Care Plan has been V covering Doula services since January 1, 2025. As a VCHCP member, you can receive doula services if you are a VCHCP member, are pregnant and the services are provided by one of VCHCP’s contracted doulas. For more information about
Antepartum Doula Assists with pregnancies that require special attention such as high-risk pregnancies (e.g., bed rest or unmanageable symptoms).
Doula services, click this link vchcp.kinsta.cloud/ DoulaServices American Pregnancy Association. (2026). Having a Doula – What are the Benefits? americanpregnancy.org/healthy-pregnancy/labor-andbirth/having-a-doula Harvard Health Publishing. (2023). What does a birth Doula do? health.harvard.edu/blog/what-does-a-birth-doulado-202311222995 Cleveland Clinic. (2025). Doula. my.clevelandclinic.org/ health/articles/23075-doula
52
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Post Partum Doula Provides assistance after delivery. They assist in adjustment of life with an infant.
Prenatal Care in your First Trimester Discomforts of pregnancy
Pregnancy is an exciting time, but it can also be stressful. Knowing that you are doing all you can to stay healthy during pregnancy and give your baby a healthy start in life will help you to have peace of mind. When you find out you’re pregnant, make your first prenatal appointment as soon as possible. Set aside time for the first visit to go over your medical history and talk about any risk factors for pregnancy problems that you may have.
You might notice changes in your body early in your pregnancy. Your breasts might be tender and swollen. Nausea with or without vomiting (morning sickness) is also common. Talk to your health care provider if your morning sickness is severe. Your next prenatal visits — often scheduled about every four weeks during the first trimester — might be shorter than the first. Near the end of the first trimester — by about 12 to 14 weeks of pregnancy — you might be able to hear your baby’s heartbeat with a small device, called a Doppler, that bounces sound waves off your baby’s heart. Your health care provider may offer a first trimester ultrasound, too. Your prenatal appointments are an ideal time to discuss questions you have. During your first visit, find out how to reach your health care team between appointments in case concerns come up. Knowing help is available can offer peace of mind.
Due date Your health care provider might do a physical exam, including a breast exam and a pelvic exam. You might need a Pap test, depending on how long it has been since your last Pap test. Depending on your situation, you may need exams of your heart, lungs and thyroid. Prenatal tests can provide valuable information about your baby’s health. Your health care provider will typically offer a variety of prenatal genetic screening tests. They may include ultrasound or blood tests to check for certain fetal genetic problems, such as Down syndrome. Your health care provider might discuss the importance of nutrition and prenatal vitamins. Ask about exercise, sex, dental care, vaccinations and travel during pregnancy, as well as other lifestyle issues. You might also talk about your work environment and the use of medications during pregnancy. If you smoke, ask your health care provider for suggestions to help you quit.
Sources: Mayo Clinic. (2024). Prenatal care: first trimester visits. mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/ in-depth/prenatal-care/art-20044882 Centers for Disease Control and Prevention. During pregnancy. cdc.gov/pregnancy/during/
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
53
Preventive Health Guidelines The 2025-2026 Preventive Health Guidelines is an excellent resource where members can find immunization schedules, preventive health screening information, and an adult preventive care timeline. The Preventive Health Guidelines include information from VCHCP, US Preventive Services Task Force (USPSTF), Centers for Disease Control (CDC), and the Agency for Healthcare Research and Quality (AHRQ) and are updated annually. Providers and members are given access to the Preventive Health Guidelines online at: vchcp.venturacounty.gov/preventiveHealthGuidelinesCommercial.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies.
VCHCP Maternal Mental Health Program and Maternal and Infant Health Program VCHCP covers at least one maternal mental health screening to be conducted during pregnancy, at least one additional screening to be conducted during the first six weeks after delivery (postpartum period), and additional postpartum screenings, if medically necessary according to your doctor. The maternal mental health screening is a part of the Plan’s Maternal Mental Health Program. The screenings do not require prior authorization and will not require any out-of-pocket expense (cost sharing). VCHCP implemented a maternal and infant equity program. This is also a part of the maternal mental health programs. The maternal and infant equity program was created to address health disparities and improve mother-child health outcomes by offering Doula services. The Doula, also called the birth doula or labor support companion, is a person trained in childbirth who provides emotional, physical, and educational support to a mother who is expecting, is experiencing labor, or has recently given birth. Their purpose is to help women have a safe, memorable, and empowering birthing experience. VCHCP covers Doula services during the member’s pregnancy, including prenatal, perinatal and postpartum stages, with a direct referral from the member’s doctor. Doula Services are included in your VCHCP Evidence of Coverage (EOC). Your doctor can find Doula providers on VCHCP’s website (vchcp.kinsta.cloud/ DoulaServices). under the “Find a Provider” section. You can call Member Services at (805) 981-5050 for Doula providers or additional information on Doula services. Reference: American Pregnancy Association. (2026). Having a Doula – What are the Benefits? Retrieved June 25, 2026, from americanpregnancy.org/giving-birth/having-a-doula 54
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Top 10 Tips To Quit Smoking
10
Top 10 Tips To Quit Smoking
QUIT COACH
TIPS TO
QUIT TOBACCO & NICOTINE
1. FIND YOUR REASON Whether it’s for your health, your family, or your wallet, find a powerful reason to get motivated. This will help you stay strong when you’re tempted. 2. SET A QUIT DATE Pick a specific date to stop. Putting it on the calendar makes your commitment real. 3. MAKE A PLAN Know your triggers (like stress, coffee, or alcohol) and plan exactly what you’ll do instead when they hit. 4. CALL FOR BACKUP You’re twice as likely to succeed with help. Call Kick It California to speak with a free Quit Coach at 1-800-300-8086 5. GET YOUR CREW ON BOARD Tell your friends and family you’re quitting. Let them know how they can support you.
Quit Now Enroll online
www.kickitca.org
KNOW IT ’S HARD TO QUIT LET ’S CHAT @kickitca
6. USE A QUITTING AID Talk to your doctor about using nicotine patches, gum, or other FDA-approved meds. They cut withdrawal symptoms and increase your chances. 7. CREATE SMOKE-FREE ZONES Make your home and car 100% smoke-free to remove temptation and help others breathe easier. 8. CHANGE YOUR MINDSET Stop seeing yourself as a smoker who is “trying not to smoke.” You are a nonsmoker now. For nonsmokers, lighting up is never an option. 9. EXECUTE ON YOUR QUIT DATE When your quit day arrives, actually stop. A plan is useless without action. 10. NEVER QUIT QUITTING Most people try several times before succeeding. If you slip up, don’t treat it as a failure. Get back on track—every attempt brings you closer to your goal.
Funded by the California Department of Public Health and First 5 California.
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
55
OPTUM Mental Health Emergency? Call 988
Mental health emergency?
Call 988. Life can be challenging. If you or someone you care about is struggling, know that help is available 24 hours a day. Call or text 988 if you have:1 • Thoughts of suicide • A mental health crisis • A substance use crisis The 988 Suicide & Crisis Lifeline connects you to caring support from a trained crisis counselor. There is hope. Call or text 988 today.
Every 11 minutes someone in the U.S. dies by suicide.2
1 of 5 high school students in the U.S. have seriously considered suicide.3
More than 50% of people in the U.S. will be diagnosed with mental illness during their lifetime.4
Prefer to chat? Visit 988lifeline.org.
1. Substance Abuse and Mental Health Services Administration. 988 key messages. samhsa.gov/find-help/988/key-messages. Last updated April 22, 2022. Accessed May 5, 2022. 2. Centers for Disease Control and Prevention (CDC). Facts about suicide. cdc.gov/suicide/facts/index.html. Last reviewed April 6, 2022. Accessed May 5, 2022. 3. Ivey-Stephenson AZ, Demissie Z, Crosby AE, et al. Suicidal ideation and behaviors among high school students — youth risk behavior survey, United States, 2019. cdc.gov/mmwr/ volumes/69/su/su6901a6.htm?s_cid=su6901a6_w. MMWR Suppl. 2020;69(1):47–55. Last reviewed August 20, 2020. Accessed May 5, 2022. 4. CDC. About mental health. cdc.gov/mentalhealth/learn/index.htm. Last reviewed June 28, 2021. Accessed May 5, 2022.
56
Member Newsletter
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Frequently asked questions about 988 What is 988? Dialing 988 connects you to the 988 Suicide & Crisis Lifeline. It’s available 24/7, and interpretation services are available in 150 languages. 1-800-273-TALK (8255) is still another way to reach the Lifeline. When should I call 988? Do I have to be suicidal to call? You can call 988 anytime you or a loved one is experiencing a mental health crisis. A crisis can look very different for everyone, so whatever feels like a mental health crisis to you is the right reason to call. Common reasons to call include having thoughts of suicide, feeling depressed or anxious, feeling overwhelmed or agitated, feeling like you cannot cope with the stress in your life, or needing advice on how to help a family member. Some callers need help with substance use, self-harm or feelings of wanting to hurt others. Is calling 988 the same as calling 911? Not exactly. When you call 911, you speak to a 911 operator who then sends help to you and gets off the phone. When you call 988, you are connected right away with the crisis worker who will help you during that call. Think of calling 988 as more like contacting someone to help you in the moment, not just as a person who will send someone else to help you. Nearly 90% of crisis calls to the Lifeline are resolved over the phone. If you or someone else is in life-threatening danger or has already caused self-harm, please call 911 so help can be sent right away. What happens when I call 988? When you dial 988, you will hear a message saying that you have contacted the 988 Suicide & Crisis Lifeline. You will be told to press 2 for Spanish and press 1 for veterans/service members. If you don’t select either option, your call will be routed to the Lifeline center nearest to you, based on your phone’s area code. What if I don’t want to talk to someone on the phone? You can text 988 and you will be given a short survey so the crisis center can understand what you’re going through, and then you’ll be connected with a counselor. If you’re more comfortable using a chat feature, visit suicidepreventionlifeline.org/chat. Similar to texting, you’ll be given a short survey so the crisis center can understand what you’re going through. You’ll then be connected with a counselor.
If you have thoughts of hurting yourself or others — or you know someone having those thoughts — seek help right away. If you or someone you know is in immediate danger, call 911 — or go to the closest emergency room. To reach a trained crisis counselor, call the 988 Suicide & Crisis Lifeline (previously known as the National Suicide Prevention Lifeline) at 988 or 1-800-273-TALK (1-800-273-8255). You may also text 988 or chat at 988.lifeline.org. The lifeline provides 24/7 free and confidential support.* *The Lifeline provides live crisis center phone services in English and Spanish and uses Language Line Solutions to provide translation services in over 250 additional languages for people who call 988. Optum does not recommend or endorse any treatment or medications, specific or otherwise. The information provided is for educational purposes only and is not meant to provide medical advice or otherwise replace professional advice. Consult with your clinician, physician or mental health care provider for specific health care needs, treatment or medications. Certain treatments may not be included in your insurance benefits. Check your health plan regarding your coverage of services. Optum® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are trademarks or registered marks the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. © 2022 Optum, Inc. All rights reserved. WF7297820 219453-052022
Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
57
GENDER INCLUSIVE, SENSITIVE LANGUAGE IS IMPORTANT Communication is crucial as it brings awareness, enables change, and promotes transparency and accountability. Language and images powerfully reflect and influence attitudes, behaviors, and perceptions – they shape people’s reality. Gender inclusive and sensitive language is important because it minimize stereotypes, promotes equality by avoiding language that favors one sex over another, and creates a more inclusive environment where everyone feels respected and acknowledged, contributing
to positive social change and reducing gender bias in communication. VCHCP has a Provider toolkit on the website that providers can utilize when formulating written materials for members, ensuring that written materials are compliant with the National Culturally and Linguistically Appropriate Service (CLAS) Standards and Section 1557 of the Affordable Care Act (ACA).
GENDER AFFIRMING PROCEDURES AND SERVICES Members should have access to affordable, high-quality health care, regardless of race, color, national origin, sex, gender identity, sexual orientation, age, or disability. Health plan benefits for transgender services are part of our commitment to the transgender community. Ventura County Health Care Plan (VCHCP) adheres to the guidelines of the World Professional Association for Transgender Health (WPATH) for gender-affirming care benefits. VCHCP does not limit sex-specific recommended preventive services based on your gender identity or recorded gender. To access the most current VCHCP policy for Gender Affirming procedures, please visit: vchcp.venturacounty.gov/GenderAffirmingProcedures/.
To access the Standards of Care developed by the World of Professional Association for Transgender Health (WPATH), please visit the website at wpath.org/publications/soc8/. To access Optum Health’s Behavioral Health Clinical Criteria, please visit the website at: public.providerexpress.com/content/ope-provexpr/us/ en/clinical-resources/guidelines-policies.html. Adopted Behavioral Health Clinical Criteria: • American Society of Addiction Medicine (ASAM) Criteria®, Fourth Edition • Level of Care Utilization System (LOCUS) • Child and Adolescent Service Intensity Instrument (CASII) • Early Childhood Service Intensity Instrument (ECSII)
If you have questions, concerns, or would like a copy mailed to you at no cost, please contact Ventura County Health Care Plan at (805) 981-5050 or (800) 600-8247.
VCHCP
NETWORK
NEW TO THE NETWORK
Allison Han, N.P., a Nurse Practitioner at Renal Consultants of Ventura County in Camarillo, Oxnard and Ventura, has been added effective April 2026. Amy Lin, M.D., a Family Medicine physician at
Adventist Health Physicians Network in Moorpark, has been added effective April 2026.
Carly Visger, P.A.-C., a Physician Assistant at
Erica Johnson, R.D.N., a Registered Dietician
California Retina Consultants in Oxnard and Simi Valley, has been added effective May 2026.
Nutritionist at 360 Nutritionist Consulting in Camarillo, has been added effective May 2026.
Cecil Shikiya, D.O., a Family Medicine physician at
Jenna Gharzeddine, M.D., an Internal Medicine at Adventist Health Physicians Network located at 2950 Sycamore Dr., Ste. 300 in Simi Valley, has been added effective April 2026.
HMG Community Clinic in Oxnard, has been added effective April 2026.
at Cardiology Associates Medical Group in Oxnard and Ventura, has been added effective June 2026.
Daniel Takeda, M.D., a Family Medicine physician at Adventist Health Physicians Network located at 2950 Sycamore Dr., Ste. 300 in Simi Valley, has been added effective April 2026.
Briana Landecker, C.P.N.P., a Pediatric Nurse
Desiree Sanchez, M.D., a Urologist at Adventist
Anna Luisa Marroquin, P.A.-C., a Physician Assistant
Practitioner at Coastal Kids located at 425 Haaland Dr., Ste. 104 in Thousand Oaks, has been added effective April 2026. 58
For a full list of participating providers please see our website: vchcp.venturacounty.gov/ProviderSearch.php or contact Member Services at (805) 981-5050 or (800) 600-8247.
Member Newsletter
Health Physician Network located at 2750 Sycamore Dr., Ste. 202 in Simi Valley, has been added effective April 2026.
FA LL u SEP T E M BER 2026 | vchcp.venturacounty.gov
Jessica Leopaldi, R.D.N., a Registered Dietician
Nutritionist at 360 Nutritionist Consulting in Camarillo, has been added effective April 2026. Liliana Guadron-Hernandez, P.A.-C., a Physician
Assistant at HMG Community Clinic in Oxnard, has been added effective April 2026.
Marc Judd, M.D., an Internal Medicine physician at Adventist Health Physicians Network in Moorpark, has been added effective May 2026.
Carla Tahan, M.D., a Pediatrician at Coastal Kids located at 33 W. Thousand Okas Blvd., Ste. A-2 in Thousand Oaks, has left effective September 2026.
Renuka Rudra, M.D., a Physical Medicine & Rehabilitation specialist at Boomerang Healthcare in Oxnard, has left effective April 2026.
Merlin Medical Supply, a Durable Medical
Christina Deal, F.N.P., a Nurse Practitioner at Ideal
Thomas Fogel, M.D., a Radiation Oncology specialist
Equipment supplier in Camarillo, has been added effective May 2026.
Womens Health Specialist in Ventura, has left effective April 2026.
at Cabrillo Radiation Center in Ventura, has retired effective December 2025.
Parhum Namdaran, M.D., a Cardiovascular Disease
Dane Petersen, F.N.P., a Nurse Practitioner at Cardiology Associates Medical Group in Oxnard and Ventura, has left effective November 2025.
Timothy Jones, P.A.-C., a Physician Assistant at
specialist at Adventist Health Physicians Network located at 124 Macaw Ln., and 2750 Sycamore Dr., Ste. 209 in Simi Valley, has been added effective May 2026. Renuka Rudra, M.D., a Physical Medicine &
Rehabilitation specialist at Ventura Orthopedics Medical Group in Oxnard and Thousand Oaks, has been added effective July 2026. Sami Daher, D.O., a Family Medicine physician at
Adventist Health Physicians Network located at 2950 Sycamore Dr., Ste. 300 in Simi Valley, has been added effective July 2026. Shaham Mumtaz, M.D., a Gastroenterologist at
Genesis Healthcare Partners in Camarillo and Oxnard, has been added effective June 2026. Stephen Evans, M.D., an Internal Medicine physician
at Ojai Valley Family Medicine Group in Ojai, has been added effective July 2026. Tanner Green, P.A.-C., a Physician Assistant at Ventura Orthopedics Medical Group in Thousand Oaks and Simi Valley, has been added effective April 2026.
LEAVING THE NETWORK Alexander De Castro-Abeger, M.D., an
Ophthalmologist at Miramar Eye Specialists in Camarillo, Thousand Oaks and Ventura, has left effective June 2026. Ali Sovari, M.D., a Cardiac Electrophysiologist at Cabrillo Cardiology Medical Group in Camarillo and Oxnard, has left effective May 2026. Ashley Netrow, F.N.P., a Nurse Practitioner at Clinicas
Del Camino Real Inc., Ojai Valley Community Health Center, has left effective April 2026. Bavand Youssefzadeh, M.D., an Ophthalmologist at
Access Eye Institute in Oxnard and Westlake Village, has left effective June 2025. Brianna Ennis, M.D., a Pediatrician at Mandalay
Bay Women & Children’s Medical Group (VCMC) in Oxnard, has left effective April 2026. Carey Chronis, M.D., a Pediatrician in Ventura, has
Dean Smith, M.D., a Family Medicine physician at Dean W. Smith, MD A Medical Corporation in Ventura, has left August 2026. Eeman Hasan, P.A.-C., a Physician Assistant at
Clinicas Del Camino Real Inc., in Moorpark, has left effective June 2026. Emily Sim, P.A.-C., a Physician Assistant at Ventura Orthopedics Medical Group in Oxnard, has left effective February 2026. George Yu, M.D., a Pulmonary Disease specialist in
Camarillo, has retired effective July 2026. Grace Sun, M.D., a Pediatric Dermatologist at
Dermatology Medical Group in Oxnard, has left effective August 2026. Irish Dawn Dorsey, P.A.-C., a Physician Assistant at Matthew L. Bloom, DO PC in Oxnard and Ventura, has left effective June 2026. Ivy Cruz, F.N.P., a Nurse Practitioner at Clinicas Del
Camino Real Inc., in Moorpark, has left effective March 2026. Justin Salerno, M.D., an Obstetrics & Gynecology specialist at Clinicas Del Camino Real Inc., in Santa Paula, has left effective May 2026. Kelly Olson, P.A.-C., a Physician Assistant at Ventura Orthopedics Medical Group in Simi Valley, has left effective March 2026.
Ventura Orthopedics Medical Group in Thousand Oaks, has left effective February 2026.
CHANGES Adventist Health Physicians Network located at
2755 Alamo St., Ste. 201 has permanently closed their doors effective May 2026. Alicia Jones, C.P.N.P., a Pediatric Nurse Practitioner has relocated to Mandalay Bay Women & Children’s Medical Group (VCMC) in Oxnard, effective April 2026. Anacapa Neurosurgery (VCMC), Anacapa Plastics and Hand Reconstruction (VCMC), and Anacapa Urology Clinic (VCMC) in Ventura, are now called Surgery Specialty Clinic (VCMC), effective July 2026. Boomerang Healthcare, a Pain Management facility in Oxnard, has permanently closed their doors effective April 2026. College Pharmacy Home Health, a Durable Medical Equipment supplier in Ventura, has permanently closed their doors effective March 2026. L. E. Brand, MD Corporation, in Camarillo has moved to a new location within Camarillo, effective June 2026. Santa Paula Hospital Clinic (VCMC) is no longer providing medical services, effective June 2026. Southern California Reproductive Center has added a new location in Westlake Village, effective August 2026.
Krysta Carlson, P.A.-C., a Physician Assistant at Clinicas Del Camino Real Inc., in Newbury Park, has left effective June 2026. Lilia Coppa, M.D., a Pediatrician at Coastal Kids in
Oxnard, has left effective August 2026. Mizin Kawasaki, M.D., a Pediatrician at Coastal Kids located at 425 Haaland Dr., Ste. 104 in Thousand Oaks, has retired effective June 2026. Nancy Menges, P.A.-C., a Physician Assistant at
Adventist Health Physicians Network located at 2950 Sycamore Dr., Ste. 200 in Simi Valley, has left effective May 2026.
retired effective July 2026. Please contact Member Services at (805) 981-5050 if you need assistance or hard copies. vchcp.venturacounty.gov | FA LL u SEP T E M BER 2026 Member Newsletter
59
2220 E. Gonzales Road, Suite 210-B Oxnard, CA 93036