PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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Work, Family or Eligible Life Status Changes You have a qualified work, family or eligible life status change if: You marry or you meet the criteria to add a domestic partner or civil union partner (see definition in the Partner Information Guide) You have a newborn, you adopt a child (under age 26) or a child (under age 26) is placed with you for adoption You have a court order requiring coverage of a child (under age 26) under an Advocate health plan You divorce or legally separate from your spouse, have your marriage annulled or end a domestic partnership or civil union partnership Your child becomes eligible or is no longer eligible for coverage You or your dependents lose coverage under another employer’s plan You, your spouse’s (or domestic partner’s or civil union partner’s) or child’s employment status changes and loses eligibility for his or her group coverage You, your spouse (or domestic partner or civil union partner) or child start or change employment status and become eligible for coverage under the Plan Your spouse (or domestic partner or civil union partner) or child dies You or a dependent loses coverage under Medicaid or SCHIP, or becomes eligible for a state premium assistance subsidy from Medicaid or SCHIP 1 You, your spouse (or domestic partner or civil union partner) or child becomes entitled to or loses eligibility for Medicare You or your spouse’s (or domestic partner’s or civil union partner’s) benefit coverage or cost of coverage under the Plan changes significantly, You or your spouse (or domestic partner or civil union partner) go on an unpaid leave of absence, or You, your spouse (or domestic partner or civil union partner) or your child change place of residence that results in a gain or loss of eligibility for coverage. 1 You may request coverage due to this status change within 60 days after the event. 14 Rehire Policy If you terminate employment with an Advocate Company or reduce your hours of work to a nonbenefits eligible status and then at least 30 days later become benefits-eligible or return to work with an Advocate Company, you will be treated as a new hire for purposes of participation in the Plan. There will be a 30-day waiting period before benefits can become effective, and you must call the Advocate Benefits Service Center at 800.775.4784 in order to elect medical coverage under this PPO/DRP option or any other medical plan option. If you are rehired or become benefits-eligible in less than 30 days after your termination of employment or loss of benefitseligible status, you will be re-enrolled in the PPO/ DRP coverage option as was in place immediately before your termination of employment or loss of benefits-eligible status. If you are rehired by an Advocate Company within 12 months of your termination of employment with and while receiving severance benefits from an Advocate Company, your participation in the Plan will be reinstated with the same benefit elections as those in effect immediately prior to your termination of employment.
PPO/DRP Benefits The PPO/DRP coverage allows you to decide at any time whether to use participating providers, specialists or hospitals (that is, you choose to receive care “in-network”) or nonparticipating providers, specialists and hospitals (that is, you choose to receive care “out-of-network”). If you choose: Participating providers, specialists and hospitals—you receive a higher level of benefits and reduce your out-of-pocket costs, and there are no claim forms to file. Nonparticipating providers, specialists and hospitals—in general, plan benefits will be lower, you will pay more toward the cost of the covered services that you and your eligible family members receive, and there are claim forms to file. Whenever you require medical services, you should call the PPO/DRP administrator at the number shown on your coverage ID card to make sure your provider is still in the network. Choosing a Provider The PPO/DRP provider network is a group of physicians, hospitals and other providers who have contracted to deliver their services at a discount. To find a participating provider, first check with your physician—he or she may already be participating in the PPO/DRP provider network. For complete and up-to-date information regarding participating physicians and hospitals in your location, go to Advocate Benefits Service Center—www.advocatebenefits.com (go to Benefits Information > Medical Benefits > Physician Search.) 15 Important! Be aware that physicians and facilities listed in the provider directory or on the web page are subject to change. The most complete and up-todate information regarding participating physicians and facilities is available by calling the PPO/DRP administrator at the number shown on your coverage ID card. Always check directly with your provider of choice—at each visit or point of contact—to confirm that your physician is currently participating in the network. Coverage Amounts Deductibles The deductible is the amount of covered medical expenses you pay each year toward the cost of covered medical services before benefits begin (see PPO/DRP At-A-Glance, page 6). If you have associate + child(ren), associate + spouse/domestic partner/civil union partner or family coverage, the deductible may be satisfied by covered expenses incurred by one or a combination of two or more family members.
Page 1 and 2: PPO/DRP Medical Plan
Page 3 and 4: PPO/DRP Medical Plan If you are an
Page 5 and 6: You also may be invited to particip
Page 7 and 8: Services In-Network Out-of-Network
Page 9 and 10: Type of Services In-Network Out-of-
Page 11 and 12: Incapacitated Dependents A child wi
Page 13: You may be able to enroll yourself
Page 17 and 18: Medically Necessary Services A proc
Page 19 and 20: You must call to schedule a non-urg
Page 21 and 22: Chiropractic Care The Plan will pay
Page 23 and 24: The PPO/DRP pays benefits if hospic
Page 25 and 26: Benefits for Newborns When you or a
Page 27 and 28: Other Covered Services Besides the
Page 29 and 30: Weight reduction or treatment of ob
Page 31 and 32: Making a Claim Filing a Claim Any c
Page 33 and 34: However, if a claim is submitted th
Page 35 and 36: The consulting health care professi
Page 37 and 38: If the claimant’s request is comp
Page 39 and 40: Other Plan Information When Medical
Page 41 and 42: Reimbursement/Subrogation You and y
Page 43 and 44: Assignment of Benefits A Qualified
Page 45 and 46: Your Benefits If you elect to conti

PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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