PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Chapter 1: Getting started as a member Our service area includes these counties in New York State: Bronx, Kings, Queens, New York, Richmond, Nassau, Suff olk, Westchester and Rockland If you plan to move out of the service area, please contact Customer Service (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. SECTION 3 WHAT OTHER MATERIALS WILL YOU GET FROM US? Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Here’s a sample membership card to show you what yours will look like: SAMPLE SAMPLE As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your plan membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Customer Service right away and we will send you a new card. (Phone numbers for Customer Service are printed on the back cover of this booklet.) Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers and pharmacies in the plan’s network What are “network providers”? Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. 5
6 2013 Evidence Evidence of Coverage Coverage for PPO II Chapter 1: Getting started as a member Why do you need to know which providers are part of our network? As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefi ts and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using the plan’s coverage for your medical services) for more specifi c information. What are “network pharmacies”? Our Provider/Pharmacy Directory gives you a complete list of our network pharmacies – that means all of the pharmacies that have agreed to fi ll covered prescriptions for our plan members. Why do you need to know about network pharmacies? You can use the Provider/Pharmacy Directory to fi nd the network pharmacy you want to use. Th is is important because, with few exceptions, you must get your prescriptions fi lled at one of our network pharmacies if you want our plan to cover (help you pay for) them. If you don’t have your copy of the Provider/Pharmacy Directory, you can request a copy from Customer Service (phone numbers are printed on the back cover of this booklet). You may ask Customer Service for more information about our network providers, including their qualifi cations, and about changes in our pharmacy network. You can also see the Provider/Pharmacy Directory at www.emblemhealth.com/ medicare, or download it from this website. Both Customer Service and the website can give you the most up-to-date information about changes in our network providers and our pharmacy network. Section 3.3 The plan’s List of Covered Drugs (Formulary) Th e plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by our plan. Th e drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Th e list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. Th e Drug List also tells you if there are any rules that restrict coverage for your drugs. We will send you a copy of the Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan’s website (www.emblemhealth.com/medicare) or call Customer Service (phone numbers are printed on the back cover of this booklet). Section 3.4 The Explanation of Benefi ts (the “EOB”): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefi ts, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. Th is summary report is called the Explanation of Benefi ts (or the “EOB”). Th e Explanation of Benefi ts tells you the total amount you have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month.
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PPO II - EmblemHealth

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