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

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In This Summary... PPO/DRP Medical Plan ...................................................... 3 Keeping Healthy: A Common Goal, A Shared Commitment ................. 4 PPO/DRP At-A-Glance ...................................................... 6 The Basics .................................................................. 10 Eligibility Cost When Coverage Begins Making Changes PPO/DRP Benefits .......................................................... 15 Choosing a Provider Coverage Amounts HealthCare Management Program Covered Services Services That Are Not Covered Prescription Benefits Making a Claim ............................................................ 31 Filing a Claim Claims and Appeal Procedures Other Plan Information ..................................................... 39 When Medical Coverage Ends Non-Duplication of Benefits Rights of the PPO/DRP Administrator Subrogation/Reimbursement Health Insurance Portability and Accessibility Act of 1996 (HIPAA) Integrating Benefits with Medicare Assignment of Benefits Coverage During Leaves and Disability Continuation of Coverage Evidence of Creditable Coverage Plan Administration 2
PPO/DRP Medical Plan If you are an eligible associate (see the Eligibility section on page 10), the Preferred Provider Organization Deductible Reimbursement Plan (PPO/DRP) coverage option offers important protection against the high cost of medical care for you and your covered family members, as described in this summary booklet. If you choose PPO/DRP coverage, it will pay benefits toward the cost of covered medical services you and your eligible family members receive from any physician or medical facility you choose—but will generally pay a higher level of benefits when services are provided by a PPO/ DRP participating provider. When you elect PPO/DRP coverage, you will automatically participate in an Advocate-funded Deductible Reimbursement Account (DRA) that you can use to offset a portion of your annual deductible. Advocate’s contribution to your DRA will be: $600—if you elect single coverage, or $1,200—if you elect associate + child(ren) or associate + spouse or family coverage. For more information about the DRA—and the Healthe Futures Account—see the Health Reimbursement Accounts Plan Summary. This is a summary of the benefits available through the PPO/DRP Medical Plan, which is a medical coverage option under the Advocate Health Care Network Welfare Benefits Plan (the “Plan”). While every effort has been made to accurately describe the Plan and the PPO/DRP Medical Plan option, this booklet—as a summary—does not cover all the details of the Plan (or the underlying medical plan options) or how the rules will apply to every person, in every situation. The complete rules that govern the Plan (and the underlying medical plan options) are contained in the official Plan document. In the event of a discrepancy between the information contained in this summary and the official Plan document, the Plan document will always govern. Advocate intends to continue the Plan, but reserves the right to amend, modify or terminate the Plan, in whole or in part, at any time for any reason. In the event of a change, the Plan document will always govern.If the Plan is terminated, your coverage will end; however, you will be entitled to Plan benefits for any covered services incurred before the date the Plan was terminated. This booklet is not a contract of employment and nothing in the Plan gives any associate the right to be retained in the service of Advocate Health Care Network (“Advocate”) or any of its affiliated companies. 3
Page 1: PPO/DRP Medical Plan
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 and 14: You may be able to enroll yourself
Page 15 and 16: PPO/DRP Benefits The PPO/DRP covera
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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