YOU CHOOSE YOUR PROVIDER AND LEVEL OF BENEFITS
Your ConnectiCare Network USA -- PPO Plan
allows you to choose the providers (doctors, hospitals, labs, etc.) for your
health care services. Each time you need services, you may choose between
providers who participate in the Private Health Care Systems, Inc. (PHCS)
network (for in-network benefits) and those who do not participate in the
network (for out-of-network benefits).
In-Network: If you use participating providers from the PHCS network, you will be eligible for a higher “in-network” level of benefits. You will be responsible for a copayment at the time of service. For the most updated list of participating providers, visit ConnectiCare’s online provider directory , or you can call toll-free: 1-866-580-7427.* On the online provider directory you simply select “ConnectiCare Network USA-PPO Plan,” and the state you would like to search. You can search by provider name, ZIP code, county, city, distance and other characteristics that are even more specific. (Participating providers for organ and bone marrow transplants are not listed on our online provider directory ; please call 1-800-562-6833 for information.)
Out-of-Network : If you use nonparticipating providers, you may be eligible for a lower “out-of-network” level of benefits. You will be responsible for an annual deductible and coinsurance. Remember, you’ll make the most of your benefits by using participating providers from the PHCS network.
YOUR PHARMACY BENEFITS If your plan has a prescription drug rider, you are eligible for prescription drug benefits. When using a participating pharmacy or our mail-order pharmacy vendor, you will be responsible only for the applicable copayment. When using a nonparticipating pharmacy, you will be responsible for paying the entire cost of your prescription at the pharmacy. We will reimburse you for covered prescription drugs at our Maximum Allowable Amount.**
FILING CLAIMS When you receive services from a participating provider or pharmacy, you do not need to be concerned with filing a claim. A participating provider or pharmacy will collect your copayment from you at the time of service and file the claim on your behalf.
When you receive services from a nonparticipating provider/pharmacy, you must send us a completed claim form (forms are available online at www.connecticare.com, or from your group benefits administrator), as well as a detailed bill from your provider or pharmacy. We will process the claim and, if it is payable, reimburse you according to the appropriate benefit level. (If the provider or pharmacy submitted the claim on your behalf, we will issue payment to the provider.)
We must receive claims within 180 days from the date the service, drug or supply was received. Claims received more than 180 days after the date will not be reimbursed.
All claims should be forwarded to:
ConnectiCare
P.O. Box 546
Farmington, CT 06034-0546
All claims from nonparticipating providers/pharmacies are subject to a
comparison with the Maximum Allowable Amount** for the service. If the charges
from the nonparticipating provider/pharmacy are higher than the Maximum
Allowable Amount for the service, the deductible and coinsurance will be
applied to the Maximum AllowablebAmount, and you are financiallybresponsible
for the remainder of thebprovider’s/pharmacy’s charges.
TO CONTACT US
By following the guidelines of “How Your Plan Works,” you’ll be making the most
of your ConnectiCare plan. For more detailed information, please see your
Benefit Summary, Certificate of Coverage or other plan documents. If you still
have questions regarding your plan, please call member services at 1-800-846-8578,
or log onto www.connecticare.com
.
Thank you for choosing ConnectiCare, one of America’s highest-rated health plans.
* Other participating provider networks may apply. Please consult your Benefit Summary, Certificate of Coverage or other plan documents for specific coverage under your plan. ** Maximum Allowable Amount: The amount of a nonparticipating provider/pharmacy’s fees that ConnectiCare uses to determine what we will reimburse under the plan. (It’s your responsibility to pay any balance.) The Maximum Allowable Amount is usually based on a specified percentile of prevailing billed charges that we use, or ConnectiCare’s fee schedule for participating providers/pharmacies. For a prescription drug or supply obtained at a pharmacy, the Maximum Allowable Amount will be the lesser of the actual charge for the drug or supply, or the negotiated contracted rate for that drug or supply that we would have paid if the drug or supply had been obtained at a participating pharmacy.
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