What's included in my health plan?
A lot! You can call our Member 360 Program at 888.422.8181 Monday–Friday, 8am–7pm (ET) as often as needed. Or email us at firstname.lastname@example.org.
Unprecedented dedicated care
Access to a nationwide network of providers and hospitals
High-quality care with pricing transparency that may result in the elimination or reduction of your out-of-pocket expenses
Nationwide emergency coverage
Healthcare is complicated, so we give you a Member 360 Program!
Our Member 360 Program takes the guesswork out of navigating your healthcare. The days of calling a health plan and getting different answers from different people are gone! Each Paradigm Health Plans Member is assigned a personal Member 360 Program Team Member who becomes your benefit advocate throughout your enrollment in Paradigm Health Plans—that means you get consistent answers you can trust! Your Member 360 Program will remove obstacles and barriers to getting the care you need. Empower you through education about your plan and how to access care when you need it.
Here's how Member 360 Program works:
Just a few easy steps!
Eliminating Barriers With our Member 360 Program
You can reach out to your Member 360 Program for just about anything related to your healthcare. Your Member 360 Program will:
- Eliminate or reduce your out-of-pocket expenses
- Educate you about your plan prior to enrollment and throughout your membership
- Locate an in-network provider and help coordinate services with providers out-of-network
- Enroll you in mail-order programs and coordinate the prescriptions you need with your doctor
- Answer billing questions and help you untangle incorrect bills
- Coordinate 2nd opinions
- Inform you of preventative services available to you
- Explain costs and co-payments
- Provide you with cost and quality information so you can make the best provider choices for you
- Inform you where and when to get care for preventative healthcare services
Staying on Course with Your Own Doctor
Paradigm offers access to a national network of thousands of high-quality, physicians, hospitals and out-patient clinics. Your employer selects your provider network prior to plan enrollment. Contact your Member 360 Program when you receive your Member Identification Cards and ask them if your preferred doctors are in the network. If your doctor is not participating, your MAP will reach out to your doctor to either facilitate enrollment in the network or work out next steps so your care isn’t interrupted!
How can I find out if my doctor is in my Network?
It’s easy! Call the Member 360 Program Team and they will help you find in-network providers or help you extend your care with your existing provider until you can transition to an in-network provider. If you cannot locate your personal provider in your network, please contact the Member 360 Program Team and they will verify the provider’s participation for you!
Member Frequently Asked Questions
> What services does Paradigm Health Plans cover?
Our health plans have different levels of coverage selected by your employer that are offered to you. To understand your level of coverage, you can review your Member Identification Card or call your Member 360 Program! Our EPO and PPO plans cover essential services that fall into the following categories:
- Outpatient care (care you get without being admitted to a hospital)
- Inpatient Care (care you get when you are admitted to the hospital by a provider or after a visit to the emergency room)
- Emergency Room Care
- Maternity and Newborn Care
- Mental Health, substance abuse disorder services, including behavioral health treatment, counseling and psychotherapy
- Prescription Drugs
- Services or devices that can help you recover after an injury or that you need for a disability or chronic condition
- Lab and Diagnostic Testing
- Preventative services, including screening test and vaccinations. For a list of covered screening tests that do not require a co-payment, click here.
> How will my pharmacy and prescription needs be handled?
Paradigm Health Plans has chosen Serve You as our Pharmacy Benefit Manager. As a plan Member, you can register for the Member Portal through serve-you-rx.com. This free, password-protected portal contains information about your benefits and will help you track and organize prescription details for yourself or your covered family Members. Using Serve You, you can:
- Compare the costs of using brands vs. generic drugs
- Keep a list of your current medications, doctors and pharmacies
- View your Medication History
- Search for in-network pharmacies by zip code, distance and 24-hour availability
Cannot find what you need? Call the Member 360 Program Team at 888.422.8181
Mail-Order Pharmacy enrollment needs to be set up for all your maintenance medications.
- Under the plan, you are allowed two refills at your local pharmacy before the prescription is denied for its status as a maintenance medication.
- Your health provider can contact your Member 360 Program Team Member by phone and fax, and send 90-day prescriptions via Escribe to our pharmacy mail-order prescription provider.
- Providers can call 800-759-3203 or fax 414-410-8181.
- Providers can contact Escribe to enroll in Serve You Direct Home Delivery.
> What Is 1.800MD?
- A convenient alternative to after-hours care!
- Telemedicine gives you immediate access to board-certified Internal Medicine and Emergency Room Physicians.
- Provides fast and convenient access to high-quality healthcare services 24/7, 365 days a year.
- To enroll in 1800-MD, call your Member 360 Program Team Member at 888-422-8181, option 3.
- After 7pm Monday-Friday and on weekends, call 1800-MD at 800-530-8666.
- For more information regarding 1800-MD, click here.
> How do I know if I am covered for a service?
Find out by contacting your Member 360 Program Team Member or emailing email@example.com.
> I’ve lost my Member Identification (ID) Card. How can I replace it?
Call the Member 360 Program Team Monday-Friday between 8am-7pm and ask for a new copy of your card.
> Urgent Care vs. Emergency Room Coverage
- An Urgent Care visit at a facility contracted by your network is covered as an office visit and requires a co-payment.
- Emergency Room visits are subject to a higher co-payment.
- If an Emergency Room visit is determined to be non-life-threatening and non-emergent, it is not covered under the policy.
- If an Emergency Room visit is denied as being non-emergent, you can initiate an appeal process for review and additional consideration.
- You can initiate an appeal process by contacting your Member 360 Program Team Member.
> What should I do if I require emergency care after hours or over the weekend?
If you require urgent care in an emergency that could not be authorized prior, please call your Member 360 Program Team Member the following day after receiving the care if services were rendered Monday-Friday. If emergency services were rendered during the weekend, please call your Member 360 Program Team first thing Monday morning.
> What if I have a chronic condition that requires coordination with my health plan and providers?
Contact the Member 360 Program Team and ask to speak with a Team Member in Medical Management. Our Disease Management Program is URAC-Accredited through American Health and targets nine prevalent conditions for which evidence-based guidelines are established to impact health. If you have a chronic condition, you can work with a one-to-one nurse coach.
All Disease Management Nurse health coaches are registered nurses and will assist you in developing a care plan to manage even the most complex diseases.