YOUR HEALTH IS OUR. cause. Out-of-Area PPO Plans. Kaiser Permanente Insurance Company

Transcription

1 YOUR HEALTH IS OUR cause. Out-of-Area PPO Plas Kaiser Permaete Isurace Compay

2 At Kaiser Permaete, we uderstad the eed to care for the whole you mid, body, ad spirit. We re here to help you take a active role i your ow health, so you ca ejoy life to the fullest. With Kaiser Permaete Isurace Compay s Out-of-Area plas, you ca ejoy may Kaiser Permaete perks like discouts o health club membership, chiropractors, massage therapists, ad more. You ca also take advatage of your ow persoal health coach ad olie health tools like health calculators, persoalized health improvemet plas, ad a medical ecyclopedia at kp.org. These are just a few of the ways we re helpig you coect with your health. Take a look at Kaiser Permaete Isurace Compay s (KPIC) Out-of-Area PPO Plas.* They re desiged for people who do t live or work iside the Kaiser Permaete Georgia metro-atlata Service Area**, but work for a employer that does. The plas give you access to major medical coverage, while at the same time givig you the freedom to choose your ow provider ad cotrol your ow out-of-pocket costs. We make it easy to access the care you eed whe you eed it. Each time you eed medical care, you ca choose either: Participatig Provider (PHCS etwork) No-Participatig Provider Access to over 450,000 PHCS providers aroud the coutry.*** Lower out-of-pocket costs, i most istaces. No claim forms. Access to ay licesed provider. Higher out-of-pocket costs, i most istaces. I most istaces the patiet completes ad files a medical claim form for reimbursemet. * PPO Beefits are uderwritte by Kaiser Permaete Isurace Compay (KPIC), a subsidiary of Kaiser Foudatio Health Pla, Ic. (KFHP). ** The Service Area icludes Barrow, Bartow, Butts, Carroll, Cherokee, Clayto, Cobb, Coweta, Dawso, DeKalb, Douglas, Fayette, Forsyth, Fulto, Gwiett, Hall, Haralso, Heard, Hery, Lamar, Meriwether, Newto, Pauldig, Pickes, Pike, Rockdale, Spaldig, ad Walto couties. 2 *** Kaiser Permaete Isurace Compay (KPIC) has cotracted with PHCS, a atioal preferred provider orgaizatio etwork that cotracts with physicias, hospitals, ad other health care providers. To fid the earest PHCS provider i your area, please refer to the PHCS provider directory available from your employer or the PHCS Web site at phcs.com.

3 Choose your providers Participatig Providers Whe you see Participatig Providers, usually your out-of-pocket costs are lower. You also have the flexibility to see ay physicia or hospital participatig i our etwork. (For a listig, visit phcs.com/kaiser or cotact your beefits maager.) You ll be resposible for a copaymet at each physicia office visit. For certai services, a deductible ad coisurace (a percetage of the Maximum Allowable Charge*) will apply. Most Participatig Providers will file your claims for you ad collect the copaymet ad/or coisurace at the time you are see. No-Participatig Providers If you already have a doctor you kow ad like, ad that provider is ot oe of our Participatig Providers, you ca still see him or her. No-participatig Providers iclude ay other licesed doctor you choose. If you choose this optio, your out-of-pocket expeses are geerally higher tha if you receive care from a Participatig Provider. Whe you see No-participatig Providers, you will be resposible for meetig a aual deductible (for most services) ad payig coisurace. (Paymets are based upo the Maximum Allowable Charge* for covered services.) You may have to pay the full cost for each visit up frot ad file a claim for reimbursemet. Claims paymet iformatio will be prited o the back of your ID card. It is very importat that the claim is set to the correct address. For more iformatio about your health care coverage, please see your summary of beefits chart. * The Maximum Allowable Charge may be less tha the amout actually billed by the provider. Covered persos are resposible for paymet of ay amouts i excess of the Maximum Allowable Charge for a covered service. Maximum Allowable Charge is the lesser of the Usual, Customary, ad Reasoable Charges, the Negotiated Rate, ad the Actual Billed Charges for covered services. 3

4 Emergecy care If you have a medical emergecy, call 911 or go to the earest emergecy room. A emergecy is a coditio of sudde oset ad sufficiet severity that would lead a prudet lay perso to coclude that his or her life, health, limbs, or bodily fuctio is i serious jeopardy. If you receive emergecy treatmet, you will be required to pay a copaymet. If you are admitted to the hospital, the emergecy copaymet will be waived. I the evet you are admitted to a hospital as a result of a emergecy, you, your doctor, or aother resposible party should otify SHPS at withi 24 hours of admissio, or as soo as reasoably possible. This will allow us to cosult with the physicia providig your care, ad to coordiate further medical care if ecessary. Emergecy care will be reviewed for eligibility ad medical ecessity i accordace with terms of the Group Policy. Choose your pharmacies Participatig pharmacies With your KPIC Out-of-Area PPO membership, you ca fill covered prescriptios at ay of our Participatig pharmacies (through the MedImpact MedCare Pharmacy Network*) aroud the coutry. Some of the larger Participatig pharmacies iclude, but are ot limited to:* Rite Aid Target Stores Costco K-Mart Publix Walgrees Kroger The Medicie Shoppe * Note: Participatig Pharmacies are subject to chage, ad all idividual stores withi a chai may ot ecessarily participate. Participatig pharmacies cotract with MedImpact Healthcare Systems, Ic., a atioal Pharmacy Beefits Maagemet (PBM) compay. Some local idepedetly owed pharmacies ot listed i this brochure may cotract with MedImpact. To fid out if a specific pharmacy is part of MedImpact s MedCare pharmacy etwork, cotact MedImpact at , or visit MedImpact.com. 4

5 Your beefits iclude geeric preferred, brad preferred, ad brad o-preferred prescriptio drugs. Copaymets for each will be differet, with brad o-preferred geerally havig the highest copaymets. I some plas, you also have to pay a pharmacy deductible whe usig these beefit levels. The three categories of drugs are defied below: Geeric Preferred drug a prescriptio drug that does ot bear the trademark of a specific maufacturer. It is chemically the same as, ad geerally costs less tha, a brad ame prescriptio drug. Brad Preferred drug a prescriptio drug that has bee pateted, is oly produced by oe maufacturer, ad is listed by us as a drug preferred or favored to be dispesed. Brad No-preferred drug a prescriptio drug that has bee pateted, is oly produced by oe maufacturer, ad is ot listed by us as a drug preferred or favored to be dispesed. For questios about the coverage level for a specific drug, or for a complete list of Participatig pharmacies i your area, please cotact MedImpact at See the accompayig summary of beefits for specific beefit iformatio. No-participatig pharmacies You ca go to ay licesed pharmacy ad pay a coisurace for prescriptios. However, it is importat to remember that whe fillig your prescriptio at o-participatig pharmacies, you most likely will have to pay full price for the medicatio ad the submit a claim form for reimbursemet. Your pla may also have a pharmacy deductible. For more iformatio The eclosed summary of beefits chart (if icluded) will provide you with additioal iformatio about your health coverage. Oce erolled i the Out-of-Area PPO Pla, you will receive more detailed iformatio icludig a KPIC Certificate of Isurace, a Schedule of Coverage, ad your KPIC ID card. Your ID card lists the toll-free umbers for you to call should you have ay questios regardig eligibility or claims. (See the Frequetly asked q uestios sectio o pages 6-7 for more details.) 5

6 Frequetly asked questios Q. How do I select a doctor? A. You ca choose from oe of our Participatig Providers by visitig the PHCS Web site at phcs.com/kaiser or callig PHCS at To select a doctor that s ot listed o the PHCS Web site (No-participatig Provider), just call that doctor s office directly. Q. What are my beefits? A. A summary of beefits may accompay this brochure. For a complete erollmet kit, see your employer. For a more detailed descriptio about your beefits, read your Certificate of Isurace ad Schedule of Coverage. If you have questios about beefits, cotact a KPIC Member Services represetative. Q. Will the provider or pharmacy file claims for me? A. Most Participatig Providers or pharmacies will file your claims for you. However, if your provider or pharmacy chooses ot to file the claim, you will have to pay the full cost at the time of service ad file a claim for reimbursemet. Whe you visit a o-participatig Provider or pharmacy, you will most likely have to pay at the time of service ad file a claim to be reimbursed. Q. How do I get medical claim forms? A. To get a medical claim form, cotact your employer or call the Kaiser Permaete Isurace Compay Member Services Departmet at , 7 a.m.-9 p.m. (EST), Moday through Friday. Claims should be mailed to: Kaiser Permaete Isurace Compay P.O. Box Plao, TX This iformatio will also be prited o the back of your ID card. It is very importat that the medical claim be set to the correct address for timely processig. Q. How do I get pharmacy claim forms? A. To get a pharmacy claim form, call the MedImpact Pharmacy Help Desk at , 8 1 a.m. (EST) Moday through Friday, from 9 a.m. 10 p.m. (EST) o Saturday, ad from 10 a.m. 10 p.m. o Suday. You ca also visit medimpact.com. Pharmacy claims should be mailed to: MedImpact Healthcare Systems, Ic Treea Street; 5th Floor Sa Diego, CA It is very importat that the pharmacy claim be set to the correct address for timely processig. Q. Which pharmacies are participatig i my local area? A. To locate the most coveiet local pharmacy, call the MedImpact Pharmacy Help Desk at You ca also visit medimpact.com ad use the Pharmacy Locator. 6

7 Q. How do I trasfer a prescriptio to a Participatig pharmacy? A. Simply tell the pharmacist at the Participatig pharmacy that you would like to trasfer a prescriptio. Give the pharmacist the ame ad phoe umber of the pharmacy you previously used ad the prescriptio umber from the drug label. The pharmacist will do the rest. Q. Will I have to get preauthorizatio to receive care? A. I some cases, yes. Preauthorizatio is required for certai covered services. That meas you must get preapproval before receivig these services. KPIC has partered with SHPS, a leader i utilizatio maagemet, to make sure that you receive the appropriate medical services ad cotrol your out-ofpocket costs. For a listig of covered services ad more iformatio o preauthorizatio, please see the summary of beefits ad the Preauthorizatio Brochure that may be eclosed. Failure to obtai preauthorizatio may result i pealties agaist your beefit paymet, or we may dey all or part of your claim. For preauthorizatio, call SHPS at , 24 hours a day, seve days a week. Q. Does a emergecy room visit require preauthorizatio? A. No. You ca get emergecy care from the earest available facility. If you are admitted to the hospital for emergecy care or surgery, you or aother resposible party are required to otify SHPS at the umber o the back of your health pla card withi 24 hours of the admissio or as soo as reasoably possible: (available 24 hours a day, seve days a week). Q. If my doctor says he/she does ot accept Kaiser Permaete Isurace Compay patiets, who should he/she call to cofirm my coverage? A. Call Kaiser Permaete Isurace Compay Member Services Departmet at , 7 a.m.-9 p.m. (EST), Moday through Friday. Q. Ca I receive care from a Kaiser Permaete Medical Ceter? A. No. Uder the terms of your beefits as a KPIC Out-of-Area PPO member, Kaiser Permaete Medical Ceters ad their providers are ot a part of your Participatig Provider etwork. Q. How do I idetify myself as a KPIC Out-of-Area PPO member? A. Simply show your ID card wheever you get medical care or get a prescriptio filled. Q. Whom do I call regardig a Participatig Provider or to get a up-to-date provider listig? A. The Participatig Providers are cotracted with PHCS, the atio s largest preferred provider etwork. You ca cotact PHCS at , 8 a.m.-8 p.m. (EST), Moday through Friday. You ca also visit PHCS s web site, phcs.com/kaiser, to fid a Participatig Provider. Q. Whom do I call for more iformatio? A. If you or your physicia s office have specific questios about beefits, medical claims, ad eligibility, call a Kaiser Permaete Isurace Compay Member Services represetative at , 7 a.m.-9 p.m. (EST), Moday through Friday. If you have questios about a pharmacy claim or the coverage level of a specific drug, call the MedImpact Pharmacy Help Desk at , 8 1 a.m. (EST) Moday through Friday, from 9 a.m. 10 p.m. (EST) o Saturday, ad from 10 a.m. 10 p.m. o Suday. 7

8 Importat iformatio Writte iformatio o topics related to coverage offered to employer groups i the small group market is available ad ca be obtaied by callig (404) Topics iclude: 1) Factors that affect rate settig ad rate adjustmets. 2) Provisios related to reewig coverage. 3) Pla desigs ad premiums available to small groups. Note: Kaiser Permaete group plas do ot iclude a pre-existig coditio clause. Kaiser Permaete Isurace Compay OOA / Kaiser Permaete Isurace Compay