HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also: • Learn more about your plan • Find a healthcare provider near you • Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you: • How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover. • Summary of Your Costs – Lists your costs for covered services. • Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts
HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also: Learn more about your plan Find a healthcare provider near you Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you: How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover. Summary of Your Costs – Lists your costs for covered services. Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs Prior Authorization – Describes our prior authorization and emergency admission notifications provision Clinical Review – Describes our clinical review provision Personal Health Support Programs – Describes our personal health support programs Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network Covered Services –A detailed description of what is covered Exclusions – Describes services that are not covered Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness Sending Us a Claim –Instructions on how to send in a claim Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal Eligibility and Enrollment – Describes who can be covered. Termination of Coverage – Describes when coverage ends Other Plan Information – Lists general information about how this plan is administered and required state and federal notices Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 Calendar Year Deductible 7 Copayments 8 Coinsurance 8 Out-Of-Pocket Maximum 8 Allowed Amount 8 HOW PROVIDERS AFFECT YOUR COSTS 9 Medical Services 9 CARE MANAGEMENT 10 Prior Authorization 11 Clinical Review 12 Personal Hea...
