PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Table of Contents 2013 Evidence of Coverage Table of Contents Th is list of chapters and page numbers is your starting point. For more help in fi nding information you need, go to the fi rst page of a chapter. You will fi nd a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member ................................................................. 1 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources ..........................................13 Tells you how to get in touch with our plan (PPO II) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan’s coverage for your medical services ...................... 33 Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan’s network and how to get care when you have an emergency. Chapter 4. Medical Benefi ts Chart (what is covered and what you pay) ........45 Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan’s coverage for your Part D prescription drugs ...... 83 Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to fi nd out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions fi lled. Tells about the plan’s programs for drug safety and managing medications. iii
iv 2013 Evidence of Coverage for PPO II Table of Contents Chapter 6. What you pay for your Part D prescription drugs .......................... 101 Tells about the four stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages aff ect what you pay for your drugs. Explains the four cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier. Tells about the late enrollment penalty. Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs ............................. 121 Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Chapter 8. Your rights and responsibilities .........................................................129 Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)...................................... 141 Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. • Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. Th is includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. • Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan ...............................................195 Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices .......................................................................................205 Includes notices about governing law and about nondiscrimination. Chapter 12. Defi nitions of important words ........................................................209 Explains key terms used in this booklet.
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104 • Chapter 5 of this booklet.
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55 Water Street, New York, New York
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PPO II - EmblemHealth

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