Plan Certificate. Complementary Care Rider

Size: px
Start display at page:

Download "Plan Certificate. Complementary Care Rider"

Transcription

1 Plan Certificate Complementary Care Rider January 2019 F01

2

3 Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HMSA does not exclude people or treat them differently because of things like race, color, national origin, age, disability, or sex. Services that HMSA provides Provides aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please call 1 (800) toll-free; TTY 711 How to file a discrimination-related grievance or complaint If you believe that we ve failed to provide these services or discriminated against you in some way, you can file a grievance in any of the following ways: Phone: 1 (800) toll-free TTY: Compliance_Ethics@hmsa.com Fax: (808) on Oahu Mail: 818 Keeaumoku St., Honolulu, HI You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, in any of the following ways: Online: ocrportal.hhs.gov/ocr/portal/lobby.jsf Phone: 1 (800) toll-free; TDD users, call 1 (800) toll-free Mail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F, HHH Building, Washington, DC For complaint forms, please go to hhs.gov/ocr/office/file/index.html. Hawaiian: E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻŌlelo Hawaiʻi, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1 (800) TTY 711. Bisaya: ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1 (800) nga walay toll. TTY 711. Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1 (800) TTY 711. Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1 (800) toll-free. TTY 711. Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます 1 (800) をご利用ください TTY 711. まで お電話にてご連絡ください. Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1 (800) 번으로연락해주시기바랍니다. TTY 711 번으로전화해주십시오. Laotian: ກະລ ນາສ ງເກດ: ຖ າທ ານເວ າພາສາລາວ, ການຊ ວຍເຫ ອດ ານພາສາ, ບມຄ າໃຊ ຈ າຍ, ແມ ນມໃຫ ທ ານ. ໂທ 1 (800) ຟຣ. TTY 711. Marshallese: LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1 (800) tollfree, enaj ejjelok wonaan. TTY 711. Pohnpeian: Ma ke kin lokaian Pohnpei, ke kak ale sawas in sohte pweine. Kahlda nempe wet 1 (800) Me sohte kak rong call TTY 711. Samoan: MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1 (800) e leai se totogi o lenei au aunaga. TTY 711. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1 (800) TTY 711. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1 (800) toll-free. TTY 711. Tongan: FAKATOKANGA I: Kapau oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea oku nau fai atu ha tokoni ta etotongi, pea teke lava o ma u ia. Telefoni mai 1 (800) TTY 711. Trukese: MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1 (800) , ese kamo. TTY 711. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1 (800) TTY 711. NMM_1000_24715_1557_R

4

5 HAWAI I MEDICAL SERVICE ASSOCIATION Active&Fit Benefit Rider This Rider provides coverage that supplements the coverage provided in HMSA s Guide to Benefits, which describes the benefits covered under your medical plan. Your coverage under this Rider starts and ends on the same dates as your medical plan coverage. All definitions, provisions, exclusions, and conditions of HMSA s Guide to Benefits shall apply to this Rider. You are eligible to receive the following benefits: Active&Fit Program Covered You and your covered dependents age 16 and older are eligible for either the Fitness Center program or Home Fitness program as described below. Talk to your doctor before you start or change your exercise routine. Fitness Center Program. Annual membership at a participating Active&Fit fitness center or select YMCA. To find a list of participating fitness centers or YMCAs, visit the Active&Fit website or contact Active&Fit via the number listed on the last page of this Rider. You may request to change fitness centers once a month. The effective date of the change will be the first day of the month following Active&Fit s receipt and processing of your request. Please note: Services and amenities may vary by fitness center location. For example, some fitness centers may offer saunas, swimming pools, whirlpools, dance, or yoga studios. You are responsible for the cost of additional services if the location charges a separate fee outside of the standard membership; or Home Fitness Program. Up to two (2) Home Fitness Kits per calendar year. Each kit may include a DVD, a guide, and/or other products. Your kit(s) will be shipped within 10 days of enrolling with Active&Fit and selecting the Home Fitness Program option. Availability of kits may change. Please contact Active&Fit to enroll, learn more about the contents of, and to select your kit(s). Contact information can be found on the last page of this Rider. Choose from the following kits: 1. Aquatic Exercise Kit 2. Athletic Conditioning Kit 3. Barre Fitness for all Levels Kit 4. Barre Fitness Kit 5. Cardio Blast Kit 6. Cardio Pump Kit 7. Cardio Quick Fix Kit 8. Chair Aerobics Kit 9. Chair Boxing Kit 10. Chair Dancing Celebration Kit 11. Chair Dancing Kit 12. Chair Pilates Kit 13. Chair Tai Chi Kit 14. Chair Yoga Kit 15. Circuit Burn Kit 16. Diabetes Workout Kit 17. Exercises for the Bedridden Kit 18. Exercise Kit 19. High Energy Cardio Kit F01 January 2019_v2 1 11/1/2018

6 20. High Intensity Bootcamp Kit 21. Lean Body Circuits Kit 22. Pilates Kit 23. Strength and Stamina Kit 24. Stress Management Kit 25. Tai Chi Beginner Kit 26. Tai Chi for Balance Intermediate Kit 27. Total Body Workout Kit 28. Upper and Lower Body Workouts Kit 29. Walking Kit 30. Yoga Kit 31. Your Best Body Kit For ages 18 and older when enrolled in either the Fitness Center or the Home Fitness program, the following online tools are also available at The Active&Fit Connected! tool is a fun and easy way to track your exercise at a fitness center or through a wearable fitness device, app, or exercise equipment. Please note: You are responsible for the cost of purchasing additional apps, wearable fitness devices, or exercise equipment. An online newsletter 4 times a year. Other web tools like a fitness center/ymca search, online classes, and more. Your Payment Obligations Annual Deductible Your annual deductible does not apply to the Active&Fit Fitness Center Program or Home Fitness program. Annual Member Fee Fitness Center Program. $75 Annual Member Fee. Enroll with and pay your Annual Member Fee directly online at or call Active&Fit at the number listed on the last page of this Rider; or Home Fitness Program. $10 Annual Member Fee. Pay your Annual Member Fee directly online at or call Active&Fit Customer Service and select your kit(s). Please note: the following applies to the Annual Member Fee: The Annual Member Fee cannot be refunded. The Annual Member Fee is required each calendar year renewal. Annual Copayment Maximum Annual member fees for the Fitness Center or Home Fitness program do not apply toward meeting the Annual Copayment Maximum. Services Not Covered The following services are not covered: Services or supplies provided by any person, company, or provider other than a participating Active&Fit fitness center. All education materials other than those produced for the Active&Fit program by American Specialty Health Incorporated. F01 January 2019_v2 2 11/1/2018

7 Telecommunications devices, telephone handset amplifiers, television recorders, and telephones compatible with hearing aids; vision support devices. Program services or products for individuals other than the Active&Fit member. All listening devices including, but not limited to, audiotape and CD players. Services for members with serious medical conditions for which Active&Fit services are not appropriate. Fitness devices and applications that require a fee are not reimbursed by the Active&Fit program. Prescription drugs, over-the-counter products, dietary supplements, herbal supplements, vitamins, minerals, weight control or tobacco cessation products, meal-replacement beverages or powders, or any other type of food or food product, whether or not it is recommended, prescribed or supplied by a health care provider, fitness center, or program. Definition Contact Information Calendar year means the period beginning on January 1 and ending on December 1 of any year. The Active&Fit Program Phone: , Monday through Friday, 8 a.m. to 5 p.m. Hawaii Time Website: Active&Fit is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit and Active&Fit Connected! are registered trademarks of ASH and used with permission herein. F01 January 2019_v2 3 11/1/2018

8 Serving you Meet with knowledgeable, experienced health plan advisers. We ll answer questions about your health plan, give you general health and well-being information, and more. Visit hmsa.com for directions. HMSA Honolulu 818 Keeaumoku St. Monday through Friday, 8 a.m. 6 p.m. Saturday, 9 a.m. 2 p.m. HMSA Pearl City Pearl City Gateway 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. 7 p.m. Saturday, 9 a.m. 2 p.m. HMSA Hilo Waiakea Center 303A E. Makaala St. Monday through Friday, 9 a.m. 7 p.m. Saturday, 9 a.m. 2 p.m. Opening in 2019 HMSA Kahului Puunene Shopping Center 70 Hookele St. Customer Relations representatives are also available in person at our Neighbor Island offices, Monday through Friday, 8 a.m. to 4 p.m.: Kailua-Kona, Hawaii Island Henry St., Suite 301 Phone: Kahului 33 Lono Ave., Suite 350 Phone: Lihue 4366 Kukui Grove St., Suite 103 Phone: Contact HMSA. We re here for you. Call on Oahu or 1 (800) toll-free on the Neighbor Islands or Mainland. hmsa.com Together, we improve the lives of our members and the health of Hawaii. Caring for our families, friends, and neighbors is our privilege. (00) LE askhmsa

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS BASIC DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS (& CHILDREN AGE 19 THROUGH 25) PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS DELUXE DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS AGE 19 & OLDER PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person for all covered

More information

Plan Certificate. Complementary Care Rider

Plan Certificate. Complementary Care Rider Plan Certificate Complementary Care Rider July 2019 C14 Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate on

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS INDIVIDUAL DENTAL PLAN FOR CHILDREN Summary of Dental Benefits Effective January 1, 2019 CHILDREN BENEFIT ENDS AT AGE 26 MAXIMUM OUT OF POCKET (MOOP) $350 per child or $700 for 2 or more children,

More information

Luana i ke ola maika i

Luana i ke ola maika i OCTOBER 2018 Luana i ke ola maika i Enjoying good health Tips for a lifetime of good health and well-being are here. IN THIS ISSUE: Open Enrollment: Stick With HMSA We re More than What You d Expect We

More information

Luana i ke ola maika i

Luana i ke ola maika i SEPTEMBER 2017 / VOLUME 14 / ISSUE 2 Luana i ke ola maika i Enjoying good health IN THIS ISSUE Mahalo, HMSA Members! Plus 3 Steps to a Better You Tell us What You Think Fun Family Fall Recipes HMSA QUEST

More information

Say hello to Go365 by Humana for Medicare members

Say hello to Go365 by Humana for Medicare members Say hello to by Humana for Medicare members is the wellness program personalized just for you, and rewards you for making healthier choices. You are already enrolled! Follow these easy steps to get started:

More information

Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused or expired prescription drugs.

Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused or expired prescription drugs. 1 GRAB-AND-GO EMPLOYEE EDUCATION CAMPAIGN HOW-TO GUIDE National Prescription Drug Take-Back Day Expand your employees health care literacy by educating them about safe and simple ways to dispose of unused

More information

2019 Pharmacy Directory

2019 Pharmacy Directory Kaiser Permanente 2019 Directory This pharmacy directory was updated on 12/2018. For more recent information or other questions, please contact Kaiser Permanente Member Services at 1-800-805-2739 or, for

More information

2018 Pharmacy Directory

2018 Pharmacy Directory Kaiser Permanente 2018 Pharmacy Directory This pharmacy directory was updated on 02/2018. For more recent information or other questions, please contact Kaiser Permanente Member Services at 1-800-805-2739

More information

Health TALK. Mammograms save lives. Plan to quit.

Health TALK. Mammograms save lives. Plan to quit. Health TALK FALL 2018 Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day. Or it could be the fi rst day of a permanent, healthy

More information

Regence makes it easy

Regence makes it easy Regence makes it easy Regence BlueShield is changing the way people experience health care by removing friction from the system and making it easier to navigate. When you have Regence as your health plan,

More information

The benefit of knowing

The benefit of knowing The benefit of knowing Genetic testing for familial hypercholesterolemia (FH) A patient support guide 2 Does high cholesterol run in your family? In some families, high cholesterol is caused by familial

More information

ASO core offerings. Self-funded groups, sized 51 99

ASO core offerings. Self-funded groups, sized 51 99 ASO core offerings Self-funded groups, sized 51 99 2 Regence ASO core offerings Under an ASO self-funded arrangement, you define the ideal balance between control and risk. With Regence ASO, you can rely

More information

Delta Dental benefit summary

Delta Dental benefit summary Delta Dental benefit summary To find a, visit deltadentalin.com/finda and use the search tool in the blue box for Medicare Advantage PPO and Medicare Advantage Premier Providers. You may also call customer

More information

ASO core offerings. Self-funded groups, sized 100+

ASO core offerings. Self-funded groups, sized 100+ ASO core offerings Self-funded groups, sized 100+ 2 Regence ASO core offerings Under an ASO self-funded arrangement, you define the ideal balance between control and risk. With Regence ASO, you can rely

More information

Getting to the BOTTOM OF BACK PAIN

Getting to the BOTTOM OF BACK PAIN Getting to the BOTTOM OF BACK PAIN What You Should Know About Low Back Pain Do I Need an X-ray? According to the American College of Physicians, most people with low back pain feel better after a month

More information

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina.

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina. SBOSB026 2018 Summary of Benefits Humana Walmart Rx Plan (PDP) State of North Carolina Our service area includes the following state(s): North Carolina. Other pharmacies are available in our network. GNHH4HIEN_18

More information

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK?

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? A previous heart attack increases your risk of having a second one. However, you can make changes to prevent a second heart

More information

Your Feelings Matter WITH TYPE 2 DIABETES

Your Feelings Matter WITH TYPE 2 DIABETES Your Feelings Matter WITH TYPE 2 DIABETES A new diagnosis of type 2 diabetes may trigger a range of emotions from minor stress to major depression. Recognizing and addressing emotional reactions can play

More information

Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax:

Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax: Josette E. Spotts, MD, FACS 1485 W. Warm Springs Road, Suite 105 Henderson, NV 89014 Tel: 702.990.6360 Fax: 702.990.6363 Patient Name: Date: Age: Referred by: Reason for visit: Patient Name: Medical History

More information

Take Charge of YOUR COPD

Take Charge of YOUR COPD Take Charge of YOUR COPD You are the Key Did you know that Chronic Obstructive Pulmonary Disease (COPD) Flare-Ups cause your COPD to progress faster and shorten your life? The key is managing your COPD

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Preventive Care Guide

Preventive Care Guide Preventive Care Guide Kern Family Health Care wants you to get good health care. These preventive care guidelines help you stay healthy by preventing diseases or by finding them early on. Preventive care

More information

HMSA s Medicare News. Live the life you imagine.

HMSA s Medicare News. Live the life you imagine. HMSA s Medicare News Live the life you imagine. HMSA Akamai Advantage newsletter Fall 2017 What s Inside 7 Benefits for Good Health Get Vaccinated Crock-pot Chili Recipe LIVING WELL Achoo! Prevent the

More information

2019 Formulary Monthly Notice of Change

2019 Formulary Monthly Notice of Change Updated: 03/01/2019 2019 Formulary Monthly Notice of Change Medicare Advantage Employer Group Plans (EGWP) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC What is Strep? Strep or strep throat is also known as Streptococcal Pharyngitis. Pharyngitis is a type of sore throat and is a

More information

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky 1. Nondiscrimination Notice and Accessibility Requirements. ENT & Allergy Specialists will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and

More information

Living with DIABETES

Living with DIABETES Living with DIABETES Mark Your Calendar Regular tests and screenings can ensure you re on the right track with your Diabetes. You should complete the following screenings at least once or twice a year:

More information

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus You have the right to appeal our decision You have the right to ask Blue Cross of Idaho Care Plus to review our decision by asking us for an appeal. If you lose the Medicaid services appeal with Blue Cross

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE GCHJMJXEN 0916 LIVE HEALTHY ENJOY REWARDS Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

SUMMARY OF BENEFITS HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO)

SUMMARY OF BENEFITS HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) 2017 SUMMARY OF BENEFITS HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) HealthTeam Advantage, a product of Care N Care Insurance Company of North Carolina, Inc., is a Medicare Advantage

More information

APPOINTMENT OF REPRESENTATIVE

APPOINTMENT OF REPRESENTATIVE PO Box 31368 Tampa, FL 33631-3368 APPOINTMENT OF REPRESENTATIVE Name: Member number: Reference/Case number: PART 1 --- APPOINTMENT OF REPRESENTATIVE (to be filled out by member) I allow (Name of person

More information

Member Matters Newsletter

Member Matters Newsletter Member Matters Newsletter 2017 Winter Issue IN THIS ISSUE 2 A New Year with Premier HealthOne 2 Is it Time to See Your Doctor? 3 Chicken & White Bean Soup 4-5 Preventive Health Checklist 6-7 Recognizing

More information

ENJOY DR. TARA M. BRYANT THE ALL ABOUT YOU ISSUE! A Message from NEED HELP WITH HEARING AID COSTS? How to have your prescriptions

ENJOY DR. TARA M. BRYANT THE ALL ABOUT YOU ISSUE! A Message from NEED HELP WITH HEARING AID COSTS? How to have your prescriptions ENJOY THE ALL ABOUT YOU ISSUE! NEED HELP WITH HEARING AID COSTS? PAGE 7 How to have your prescriptions DELIVERED TO YOUR HOME! e f Li A Message from DR. TARA M. BRYANT PAGE 2 PAGE 6 The benefit information

More information

Family and Self Health History for Genetic Counseling. Your Personal Health History

Family and Self Health History for Genetic Counseling. Your Personal Health History Family and Self Health History for Genetic Counseling Your Personal Health History NAME: DATE OF BIRTH: 1. Your weight: (pounds) Your height: feet inches 2. Have you ever had cancer? YES NO If YES, please

More information

Notice of Denial of Medical Coverage

Notice of Denial of Medical Coverage Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under Get help & more information.

More information

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico*

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico* 209 Over-the-Counter Drugs and Vitamins - Puerto Rico* Federal Employees Health Benefits Program Effective January, 209 OVER-THE COUNTER COVERAGE FOR PUERTO RICO CATEGORY PRODUCT LIMIT Allegra-D 2 Hour

More information

Indemnity PPO Medical Plan Preventive Care Guidelines

Indemnity PPO Medical Plan Preventive Care Guidelines Southern California Drug Benefit Fund Indemnity PPO Medical Plan Preventive Care Guidelines - 2018 The Indemnity PPO Medical Plan pays 100% of the cost of coverage for many routine preventive care services

More information

CCCN Patient Questionnaire

CCCN Patient Questionnaire CCCN Patient Questionnaire Date: Patient Name: Age: Referred by: Primary Care Physician: Please provide names and phone numbers of your physicians (primary care, medical oncologist, surgeon, etc.): Reason

More information

PrimeCare of Citrus Valley

PrimeCare of Citrus Valley PrimeCare of Citrus Valley Network Directory Serving Eastvale, Corona, Norco, Riverside PRIMARY CARE FOR EVERY MEMBER OF YOUR FAMILY Family Medicine Internal Medicine Geriatrics General Practice Pediatrics

More information

Healthy Moves. A better flu season for you

Healthy Moves. A better flu season for you Fall/Winter 2017 Healthy Moves A better flu season for you Adults 65 years of age and older are a higher risk for getting and developing serious risks from the flu. Some of the risks are bronchitis, sinus

More information

Member frequently asked questions

Member frequently asked questions Magellan Complete Care of Virginia, a Medallion 4.0 program Member frequently asked questions ABOUT MEDALLION 4.0 What is Medallion 4.0? Medallion 4.0 replaces the Medicaid health plan known before as

More information

a newsletter for Viva Medicare members

a newsletter for Viva Medicare members a newsletter for Viva Medicare members Thank you for being a Viva Medicare member! Look inside for great information about how you can enjoy life to the fullest! This information is not a complete description

More information

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory This pharmacy directory is updated monthly For more recent information or other questions, please contact

More information

Thank you for being a Premera Blue Cross Medicare Supplement plan member.

Thank you for being a Premera Blue Cross Medicare Supplement plan member. P.O. Box 327 Seattle, WA 98111 February 18, 2019 MSF1 Dear : Thank you for being a Premera Blue Cross Medicare Supplement plan member. The rate table on the next page shows the following rate information:

More information

PREVENTIVE HEALTH PAYMENT GUIDELINES Effective January 1, 2017

PREVENTIVE HEALTH PAYMENT GUIDELINES Effective January 1, 2017 PREVENTIVE HEALTH PAYMENT GUIDELINES Effective January 1, 2017 Including Services Required by Affordable Care Act Women's Health (ACAWH) The following recommended services will be covered under the preventive

More information

Dental Benefits Summary

Dental Benefits Summary Active PPO With PPOII Network Participating Non-participating Annual Deductible* Individual $50 $100 Family $150 $300 Preventive Services 100% 80% Basic Services 80% 50% Major Services 60% 40% Annual Benefit

More information

Plan Certificate. Complementary Care Rider. An Independent Licensee of the Blue Cross and Blue Shield Association

Plan Certificate. Complementary Care Rider. An Independent Licensee of the Blue Cross and Blue Shield Association Plan Certificate Complementary Care Rider An Independent Licensee of the Blue Cross and Blue Shield Association January 2015 B10 HAWAI I MEDICAL SERVICE ASSOCIATION Complementary Care Rider I. ELIGIBILITY

More information

Preventive Care Coverage

Preventive Care Coverage Preventive Care Coverage 1 Table of contents 3 Know what s covered 4 For men 6 For women 9 For pregnant women 11 For children Preventive Care Coverage Know what s covered Preventive care and early detection

More information

DISCOVER Go365. Go365.com

DISCOVER Go365. Go365.com DISCOVER Go365 Go365.com GETTING STARTED READY. SET. Go365 It s simple to get started with Go365 TM. Here s how to get rewarded for your healthy behaviors. 1. Register now Download the Go365 App or visit

More information

JULY: Chair Aerobics Call café for time! 11th - All cafés. Ask the Expert: Financial Wellness and Estate Planning Call café for time!

JULY: Chair Aerobics Call café for time! 11th - All cafés. Ask the Expert: Financial Wellness and Estate Planning Call café for time! 2018 CALENDAR JANUARY: Welcome to Viva! New Member Meeting 10 am - 12 pm 8th - Grand River 9th - Hoover 10th - Montgomery 11th - Mobile 12th - Florence FEBRUARY: High Blood Pressure & Stroke Prevention

More information

2018 Formulary Annual Notice of Change

2018 Formulary Annual Notice of Change Updated: October 1, 2017 2018 Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2018 MAPD formulary. For a complete list, please

More information

ENJOY Life! 2018 BENEFITS! LOOK INSIDE FOR GREAT NEWS ABOUT YOUR

ENJOY Life! 2018 BENEFITS! LOOK INSIDE FOR GREAT NEWS ABOUT YOUR ENJOY Life! LOOK INSIDE FOR GREAT NEWS ABOUT YOUR 2018 BENEFITS! The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations,

More information

Commercial HMO/POS Effectiveness of Care Measure

Commercial HMO/POS Effectiveness of Care Measure Commercial HMO/POS Effectiveness of Care Measure HEDIS 2017 NCQA Quality Compass National Average Adult BMI Assessment 91.85% 76.17% Weight Assessment and Counseling for Nutrition and Physical Activity

More information

October is Breast Cancer Awareness Month

October is Breast Cancer Awareness Month P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Questions? Call IEHP Member Services 1-800-440-IEHP (4347) 1-800-718-IEHP (4347) for TTY users 8am 5pm Monday-Friday www.iehp.org IEHP complies with applicable

More information

Healthy Moves. Top Five Tips for Aging Better. Summer 2017

Healthy Moves. Top Five Tips for Aging Better. Summer 2017 Summer 2017 Healthy Moves Top Five Tips for Aging Better Aging is a natural process. Although, you cannot stop the clock, you can make the process smoother. Here are five tips to help you age better: 1.

More information

Connection IN THIS ISSUE: MANAGE YOUR HEALTH WITH V-CARE. CUSTOMER SERVICE AT Viva Health. Fall/Winter 2017

Connection IN THIS ISSUE: MANAGE YOUR HEALTH WITH V-CARE. CUSTOMER SERVICE AT Viva Health. Fall/Winter 2017 Connection CUSTOMER SERVICE AT Viva Health An important part of Viva Health s commitment to customer service is that we continually evaluate our own performance and strive to exceed members expectations.

More information

Preventive care coverage. Benefits designed to protect your health. bridgespanhealth.com

Preventive care coverage. Benefits designed to protect your health. bridgespanhealth.com Preventive care coverage Benefits designed to protect your health bridgespanhealth.com To find out if you re eligible for preventive coverage, call the Customer Service number on the back of your member

More information

Preventive care coverage

Preventive care coverage Preventive care coverage 1 Table of contents 3 Know what s covered 4 For men 6 For women 9 For pregnant women 10 For children Preventive care coverage Know what s covered Preventive care and early detection

More information

Delta Dental. Certificate of Coverage

Delta Dental. Certificate of Coverage Delta Dental Certificate of Coverage Delta Dental of Arkansas P.O. Box 15965 Little Rock, AR 72231 (501) 835-3400 (800) 462-5410 www.deltadentalar.com INTRODUCTION TO YOUR CERTIFICATE CERTIFICATE OF COVERAGE

More information

Stay well with this list of screenings, vaccinations and medications that are 100% covered

Stay well with this list of screenings, vaccinations and medications that are 100% covered preventive care services Stay well with this list of screenings, vaccinations and medications that are 100% covered Table of contents 3 Your preventive care benefits 4 For men 6 For women 9 For pregnant

More information

$250 (Deductible does not apply to Tier 1 and Tier 2) $500 (Deductible does not apply to Tier 1 and Tier 2)

$250 (Deductible does not apply to Tier 1 and Tier 2) $500 (Deductible does not apply to Tier 1 and Tier 2) Benefit Summary Outpatient Prescription Drug Illinois 5/50/100/250 Plan 455 Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee

More information

PREVENTIVE HEALTH PAYMENT GUIDELINES Effective June 29, 2017

PREVENTIVE HEALTH PAYMENT GUIDELINES Effective June 29, 2017 PREVENTIVE HEALTH PAYMENT GUIDELINES Effective June 29, 2017 Including Services Required by Affordable Care Act Women's Health (ACAWH) The following recommended services will be covered under the preventive

More information

Dental Benefits Summary

Dental Benefits Summary Passive PPO With PPOII Network Annual Deductible* Individual $50 Family $150 Preventive Services 100% Basic Services 80% Major Services 50% Annual Benefit Maximum $1,000 Office Visit Copay N/A Orthodontic

More information

Stay well with this list of screenings, vaccinations and medications that are 100% covered

Stay well with this list of screenings, vaccinations and medications that are 100% covered preventive care services Stay well with this list of screenings, vaccinations and medications that are 100% covered Table of contents 2 3 Your preventive care benefits 4 For men 6 For women 9 For pregnant

More information

Your Passport. Health. 2 Guide. How to use your Medicare Advantage. Preventive care benefits GUIDE. Y0062_P2H2017 Accepted

Your Passport. Health. 2 Guide. How to use your Medicare Advantage. Preventive care benefits GUIDE. Y0062_P2H2017 Accepted Your Passport 2 Guide Health How to use your Medicare Advantage preventive care benefits GUIDE Preventive care benefits Y0062_P2H2017 Accepted Preventive services checklist Talk to your doctor to determine

More information

Valley Physicians Network (VPN)

Valley Physicians Network (VPN) Valley Physicians Network (VPN) Network Directory Serving Murrieta, Wildomar, Temecula, Lake Elsinore, Menifee PRIMARY CARE FOR EVERY MEMBER OF YOUR FAMILY Family Medicine Internal Medicine Geriatrics

More information

Your Passport to Health Guide

Your Passport to Health Guide Medicare Advantage preventive care benefits Your Passport to Health Guide Regence BlueShield of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association Y0062_P2H2018 Accepted Preventive

More information

Dental Benefits Summary

Dental Benefits Summary With PPOII Network Participating Non-participating Annual Deductible* Individual $75 $75 Family $225 $225 Preventive Services 100% 90% Basic Services 80% 60% Major Services 50% 50% Annual Benefit Maximum

More information

Dental Benefits Summary

Dental Benefits Summary DMO Annual Deductible Individual Family Preventive Services 100% Basic Services 100% Major Services 60% Annual Benefit Maximum Office Visit Copay $0 Orthodontic Services (Adult and Child) $1,500 copay

More information

Dental Benefits Summary-PPO Plan

Dental Benefits Summary-PPO Plan Active PPO With PPOII Network Participating Non-participating Annual Deductible* Individual $50 $50 Family $150 $150 Preventive Services 100% 100% Basic Services 90% 80% Major Services 60% 50% Annual Benefit

More information

You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.

You ll find the most up-to-date comprehensive version of our formulary on our website,   Click on Drug Finder. 3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs

More information

Stay well with this list of screenings, vaccinations and medications that are 100% covered

Stay well with this list of screenings, vaccinations and medications that are 100% covered preventive care services Stay well with this list of screenings, vaccinations and medications that are 100% covered Table of contents 2 3 Your preventive care benefits 4 For men 6 For women 9 For pregnant

More information

Member Registration Guide GCHJUV2EN 0117

Member Registration Guide GCHJUV2EN 0117 Member Registration Guide GCHJUV2EN 0117 This guide covers Go365 registration based on two member types. Reference the applicable slides based on member type: 1. Humana Medical Members (members who have

More information

Dental Benefits Summary - Proposed EPP Plan

Dental Benefits Summary - Proposed EPP Plan PPO II Included Participating Non-participating Individual $50 Not Covered Family $150 Not Covered Preventive Services 100% Not Covered Basic Services 50% Not Covered Major Services 25% Not Covered Annual

More information

Access Network Directory Nebraska

Access Network Directory Nebraska Access Network Directory Nebraska Introduction 1 Introduction The following is a list of health care providers in this area who are in the Cigna network. Some providers may have been added or removed

More information

Dental Benefits Summary - EPP Plan

Dental Benefits Summary - EPP Plan EPP PPO II Included Participating Non-participating Individual $50 Not Covered Family $150 Not Covered Preventive Services 100% Not Covered Basic Services 50% Not Covered Major Services 25% Not Covered

More information

Dental Benefits Summary

Dental Benefits Summary Passive PPO With PPOII Network Annual Deductible* Individual $50 Family $150 Preventive Services 80% Basic Services 60% Major Services 50% Annual Benefit Maximum $1,000 Office Visit Copay N/A Orthodontic

More information

Kadlec Regional Medical Center 0118 KMC-002B

Kadlec Regional Medical Center 0118 KMC-002B Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d n

More information

Employees. Coverage. Choices. you deserve. you demand. Viva Access 2018

Employees. Coverage. Choices. you deserve. you demand. Viva Access 2018 2018 For Employees Coverage you deserve. Choices you demand. Access to all participating Viva Health Providers No referrals required to see specialists Viva Access 2018 Dear UAB Employee, e the opportunity

More information

Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH)

Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH) Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH) Important: Read this notice carefully. If you need help, you can call one of the numbers listed on the next page under

More information

SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health.

SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health. We re in this together: Quality Health Care Member FOCUS EASY CHOICE 2018 ISSUE 1 SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health. Why are

More information

Passive PPO With PPOII Network Preventive

Passive PPO With PPOII Network Preventive Dental Benefits Summary Passive PPO With PPOII Network 80th R&C OON*** Annual Deductible* Individual $50 Family $150 Preventive Services 100% Basic Services 80% Major Services 50% Annual Benefit Maximum

More information

Dental Benefits Summary

Dental Benefits Summary DMO Annual Deductible Individual Family Preventive Services 100% Basic Services 100% Major Services 60% Annual Benefit Maximum Office Visit Copay $0 Orthodontic Services (Adult and Child) $1,500 copay

More information

Dental Benefits Summary

Dental Benefits Summary DMO Passive PPO With PPOII Network Annual Deductible* Individual None $75 Family None $225 Preventive Services 100% 100% Basic Services 100% 50% Major Services 60% 50% Annual Benefit Maximum None $2,000

More information

Notice of Appeal Approval Macomb County Community Mental Health (MCCMH)

Notice of Appeal Approval Macomb County Community Mental Health (MCCMH) Notice of Appeal Approval Macomb County Community Mental Health (MCCMH) Important: This notice explains the results of your appeal. Read this notice carefully. If you need help, you can call one of the

More information

Dental Benefits Summary

Dental Benefits Summary DMO With PPOII Network Participating Annual Deductible* Individual None $50 Family None $150 Preventive Services 100% 100% Basic Services 100% 80% Major Services 60% 50% Annual Benefit Maximum None $2,000

More information

Access Network Directory Idaho

Access Network Directory Idaho Access Network Directory Idaho Introduction 1 Introduction The following is a list of health care providers in this area who are in the Cigna network. Some providers may have been added or removed from

More information

2018 Preventive Schedule

2018 Preventive Schedule 2018 Preventive Schedule Medicare-Covered Services PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat.

More information

NOTICE OF ADVERSE BENEFIT DETERMINATION Macomb County Community Mental Health (MCCMH)

NOTICE OF ADVERSE BENEFIT DETERMINATION Macomb County Community Mental Health (MCCMH) NOTICE OF ADVERSE BENEFIT DETERMINATION Macomb County Community Mental Health (MCCMH) Important: This notice explains your internal appeal rights. Read this notice carefully. If you need help with this

More information

SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health.

SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health. We re in this together: uality Health Care Member FOCUS HAWAII 2018 ISSUE 1 SCHEDULE YOUR PREVENTIVE CARE VISIT Preventive care visits, or routine checkups, are important to your health. Why are preventive

More information

PrimeCare of Riverside

PrimeCare of Riverside PrimeCare of Riverside Physician & Facilities Directory Serving Riverside and Corona PRIMARY CARE FOR EVERY MEMBER OF YOUR FAMILY Internal Medicine Geriatrics General Practice Pediatrics Having a doctor

More information