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UnitedHealthcare Community Plan 常見問題
何謂 Medicaid?
Medicaid 這項計劃針對低收入並符合特定投保資格的人,並可能因州別而異。Medicare 是為年滿 65 歲、殘障人士或罹患末期腎病的人所提供的聯邦健康保險方案。Medicare 的審核標準並不是收入,且其基本保險範圍在各州都一樣。
申請 Medicaid 時,需要準備哪些文件?
當您申請 Medicaid 時,您必須填寫一份申請表格。另需準備下列文件:
- 家庭成員的資料(姓名、出生日期和社會安全號碼)
- 租屋或貸款資料
- 開銷(水電瓦斯、托兒等等)
- 車輛資訊
- 銀行對帳單
- 收入(薪水單)
- 殘障手冊或醫療記錄,證明長期的醫療病症。
- 最近的醫療帳單
- 公民證明
- 其他必要資訊
How can I reach Customer Service?
Call 1-800-690-1606. 撥打此電話號碼免費。TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.
何謂處方藥物福利說明 (EOB)?
您使用處方藥物保險後,當月就會收到福利說明。它將會顯示您在處方藥物上所花費的總金額,以及我們為您支付處方藥物的總金額。福利說明將於每個月郵寄給您,說明您所使用的福利。
How do I keep my membership record up to date?
Please call Customer Service at 1-800-690-1606 (Calls to these numbers are free),TTY users call 1-800-884-4327 if there are any changes to your name, address, phone number or changes in health insurance coverage from other sources such as from your employer, spouse’s employer, worker’s compensation, Medicaid, or liability claims such as claims from an automobile accident. 服務時間:8 A.M to 5 P.M., Monday – Friday during your time zone.
How do I choose a PCP?
You may choose any plan provider to be your PCP. Plan Providers are listed in the provider directory or you may call Customer Service for assistance in finding a plan provider.
How can I switch to another PCP?
You may change your PCP for any reason, at any time. Customer Service will help make sure that the PCP you want to switch to is a participating provider with UnitedHealthcare Community Plan for Families. They will also check to be sure the PCP you want to switch to is accepting new patients.
What if my doctor or other provider leaves your plan?
Sometimes a PCP, specialist, clinic, hospital or other plan provider you are using might leave the Plan. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services.
What happens if I am traveling out of the UnitedHealthcare Community Plan for Families Service area and need care?
You may get care when you are outside the service area. You will usually pay higher costs for the care because you will get your care from non-plan providers, but you won’t pay extra if you are getting care for a medical emergency. If you have questions about your medical costs when you travel, please call Customer Service. Call 1-800-690-1606. 撥打此電話號碼免費。TTY users call 1-800-884-4327. This number requires special telephone equipment. Hours of Operation are from 8 A.M to 5 P.M., Monday – Friday during your time zone.
How is a "medical emergency" defined?
A "medical emergency" is when you reasonably believe that your health is in serious danger – when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.
What happens if I need a prescription filled or refilled outside my plan's service area?
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for a valid reason, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription.
If I have a prescription filled outside my plans service area for a good reason, can I get reimbursed?
You may ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage.
Note: If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.
How do I get reimbursed for prescriptions filled outside my plans service area when there was a valid reason?
When you return home, simply submit your claim and your receipt to the following address:
Prescription Solutions
P.O. Box 6082
Cypress, 加利福尼亞 90630-0082
If you submit a paper claim asking us to reimburse you for a prescription drug that is not on our formulary or is subject to coverage requirements or limits, your doctor may need to submit additional documentation supporting your request.
處方集是什麼?
處方集是本計劃所提供承保藥物的一份清單。我們一般承保我們處方集上所列的藥物,只要藥物是醫療上必要,處方藥則在網路藥房拿藥,且必須遵照其他承保規定。對於某些處方藥,我們有其他的承保規定或承保限制。
How are drugs on the formulary selected?
The drugs on the formulary are selected by our Plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the formulary. A generic drug has the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.
Not all drugs are included on the formulary. In some cases, the law prohibits coverage of certain types of drugs. In some cases, we have decided not to include a particular drug.
如何知道哪些藥物在處方集上?
You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. 您也可以造訪我們的網站,取得關於我們所承保藥物的最新資訊。
How much will I have to pay for my prescription?
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your coinsurance/co-payment depends on which drug tier your drug is in.
What if my drug isn't on the formulary?
If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered.
If Customer Service confirms that we don’t cover your drug, you have three options:
You may ask your doctor if you can switch to another drug that is covered by us.
You may ask us to make an exception (which is a type of coverage determination) to cover your drug. See your Evidence of Coverage (member handbook) to learn more about how to request an exception.
You can pay out-of-pocket for the drug and request that the Plan reimburse you by requesting an exception (which is a type of coverage determination). This doesn’t obligate the Plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the Plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.
In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.
What are network pharmacies?
A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drug. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Once you go to one, you aren’t required to continue going to the same pharmacy to fill your prescription; you may go to any of our network pharmacies.
What are "covered drugs"?
"Covered drugs" means all of the outpatient prescription drugs that are covered by our Plan. Covered drugs are listed in our formulary.
What should I do if I have a medical emergency?
If you have a medical emergency:
- Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center. You don’t need to get approval or a referral first from your PCP or other plan provider.
- Make sure that your PCP knows about your emergency, because your PCP needs to be involved in following up on your emergency care. - You or someone else should call to tell your PCP about your emergency care as soon as possible, usually within 48 hours.
如何獲得緊急需要的照護?
If, while temporarily outside the Plan’s service area, you require urgently needed care, then you may get this care from any provider. The plan is obligated to cover all urgently needed care at the cost-sharing levels that apply to care received within the Plan network.
What if I use non-plan providers to receive services that are "covered"?
Except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis, you must obtain covered services from network providers for the services to be covered. If you get non-emergency care from non-network providers without prior authorization, you must pay the entire cost yourself.
深入了解
Medicaid Managed Care