Read twu_retiree_medicare_cost.pdf text version

Memorandum

New York City Transit

Date

TO

February 1, 2007

TWU Local 100 Retired Employees in H P Medicare Cost P n I Jim Masella, Assistant Vice President, Employee Benefits

From

Re

Health Benefit Changes

b"

Please note that the following health benefit changes are being implemented. This memo provides you with information and applicable forms relating to:

I. 11.

SPECIAL OPEN ENROLLMENT PERIOD REIMBURSEMENTS

111. MANDATORY PRESCRIPTION DRUG PROGRAM IV. CONTACT INFORMATION IMPORTANT TELEPHONE NUMBERS AND WEB SITES

V.

VI. ADDRESS CHANGES

Health Plan Changes February 1,2007 Page 2

I. SPECIAL OPEN ENROLLMENT PERIOD

Ifyou do not wish to change your medical coverage, no action is required by you.

If you wish to change your health benefit coverage, you can do so during the Special Open Enrollment Period from now through March 16,2007. Your change(s) will be effective April 1,2007. Please complete, sign, and return the attached 2007 Special Enrollment Form [Attachment A], which must be received by MTA New York City Transit's Employee Benefits Office no later than March 16,2007. Your health plan choices are described below and on the attached:

A. Not Enrolled in Medicare (under age 65)

GHI Basic Option Enhancements Pre-Medicare retirees enrolled in the CHI Basic Option may choose to receive medical services from a participating or non-participating provider. If you use a participating provider, you will only be charged a $15 copayrnent for home/office visits and for outpatient hospital visits. A non-participating provider will continue to file for a reimbursement for medical services; however your reimbursement will be greater. For complete details, see GHI Retiree Benefit Description [Attachment B]. Elimination of PhannaCare Prescription Drug Plan Deductible Your prescription drug plan's deductible of $200 for individual coverage and $400 for family coverage has been eliminated. Coverage of Reversible Contraceptives in the PharmaCare Prescription Drug Your prescription drug plan has been expanded to include reversible contraceptives. This includes oral, vaginal, transdermal, and injectable dosage forms.

HIP HMO (Must live in HIP'S service area)* ISTA Health Plan (Must live m Vista's service area: gorida counties of Broward, Miami-Dade, Palm Beach)

~ h a r m a ~ a r e ' G HI7 PhannaCare GHI

1

*Your current HMO coverage will no longer be available to you when you and/or your dependent(s) become Medicare eligible based on reaching age 65 or being disabled. You must apply for the Medicare Advantage plan for your HMO in order to continue your coverage. Your plan will contact you approximately three months before your 65"' birthday with information on your options.

Health Plan Changes February 1,2007 Page 3 B. Medicare Eligible (including those on Medicare Disability) HIPIVIP Disenrollment If you decide to change from HIPNIP to the GHI Basic Option, you must disenroll from HIPNIP by completing the HIPNIP Disenrollment Form [Attachment C] . HIP Members Retired Before July 1, 1987 If you retired before July 1, 1987 and are in the HIP Medicare Cost Plan, you may remain in that plan. If you choose to change your coverage, you will not be allowed to re-enroll into the HIP Medicare Cost Plan in the future. Coverage of Reversible Contraceptives in the PharmaCare Prescription Drug

plan

Your prescription drug plan has been expanded to include reversible contraceptives. This includes oral, vaginal, transdermal, and injectable dosage forms.

Prescription Drug Medical/Hospital PharmaCare GHI BASIC OPTION HIPNIP HIPIVIP HMO Options 1 & 2 (Must live in

'H.IP1s service area)

Vision GHI HIPIVIP

HIP Medicare Cost

PhannaCare

GHI

11. REIMBURSMENTS

A. For GHI Basic Option Members:

Enhancement If you were enrolled in the GHI Basic Option on or after March 1, 2006, any medical services you already incurred will automatically be reprocessed by GHI based on the enhanced benefits. You can expect a payment to be issued directly to you by GHI for the difference between the reimbursement you received and the new reimbursement by the end of June 2007. No action is required by you. Claims Not Filed If you incurred medical services since March 1,2006 but never filed a claim with GHI, complete the GHI New Claim Form [Attachment Dl. Attach copies of your receipts and mail to GHI as soon as possible. You will then receive a reimbursement payment directly from GHI. COBRA If you were enrolled in GHI at any time since March 1,2006 and purchased medical plan COBRA coverage, you will be entitled to a refund of a portion of that premium. You can expect this refund to be issued by tlie end ofJune 2007.

Health Plan Changes February 1,2007 Page 4

B. For PharmaCare Prescription Drug Plan Members:

2005 Reimbursement If you paid any amount towards the PharmaCare prescription drug benefit deductible during 2005, PharmaCare will autoinatically send you a lump sum payment of $300. You can expect to receive this payment by the end of June. No action is required by you. 2006 and 2007 Reimbursement If you paid any amount towards the PharmaCare prescription drug benefit deductible from January 1, 2006 through the present, PharmaCare will automatically send you a lump sum reimbursement of the amount you paid toward the deductible, up to $200 for individual coverage and $400 for family coverage. You can expect to receive this payment by the end of June. No action is required by you. Reimbursement for Purchases since December 16, 2005 You will receive a reimbursement for reversible contraceptives you purchased on or after December 16,2005 less the applicable copayment provided you complete the attached Prescription Drug - Reversible Contraceptive Reimbursement Form [Attachment E . Attach copies of l your receipts and mail the completed form to PharmaCare as soon as possible. You will then receive a reimbursement payment directly from PharmaCare.

111. MANDATORY PRESCRIPTION DRUG PROGRAM

See Attachment F for a description of the PharmaCare Mandatory Prescription Drug Program.

Health Plan Changes February 1,2007 Page 5

IV. CONTACT INFORMATION

To obtain detailed information about your benefits: Visit TENSIWhat's New Human Resources Home PageIEmplo yee BenefitsITWU Local 100 Visit Extranet www.mta.info 1NYC Transit1 Employee Extranet1 Announcements or Employee Benefits1 TWU Local 100 Contact Employee Benefits by: Calling: 1-347-643-8550 (8:OO a.m.-5:30 p.m., Mon. thru Fri.) Faxing: 1-347-643-8409 Emailing: empl o~eebenefits(ir>,n~ct.com ontact TWU Local 100 Member Services by: Calling: 1-347-643-8061 or 8062 Faxing: 1-347-643-8063

c

V. IMPORTANT TELEPHONE NUMBERS AND WEB SITES

Carrier GHI HIP Vista PharrnaCare Tele~hone # (2 12) 5 0 1-4GHI (4444) 1-800-HIPTALK (800-447-8255) 1-866-847-8235 1-866-898-6404 Web Site www. ghi.com www.hi~usa.com www.vistahealthplan.com www.pharrnacare.com

VI. ADDRESS CHANGES

If you should change your address, you will need to complete the attached Change of Address Form for Retirees [Attachment GI and submit to the MTA New York City Transit Employee Benefits Office as noted on the forrn. If you have access to the internet, you may obtain this form by going to www.MTA.info and clicking on NYC Transit, Retiree Online, Forrns Library, Pensioner Forrns. Atts.

Attachment A

2007 S P E C I A L O P E N E N R O L L M E N T FORM Retired Members of TWU Local 100

EMPLOYEE INFORMATION

Please Prznt

LAST NAME FIRST NAME MI PASS #

3 MEDICAL: 1 INDIVIDUAL Check Only One:

COVERAGE ELECTION FAMILY

O GHI BASIC OPTION

HIPIHMO (Only available to those who live in the New York service area and enrolled in Medicare) HIP VIP (Only available to those who live in the New York service area and enrolled in Medicare Parts A and B) U VISTA HMO (Only available to those under age 65 and living in the Florida Counties of Broward, Miami-Dade, and

Palm Beach)

WAJYING COVERAGE:

I do not wish to enroll in health coverage. If I need to enroll at a future date, I must contact Employee Benefits at 347-643-8550.

I~~ouse~omestic Partner's Employer (if applicable)

Name:

Address: Address:

I

Insurance Carrier (if applicable):

Name:

DEPENDENT INFORMATION List all dependents you wish to have on your new election through 2007. Required Documentation for dependents not listed on your current coverage: marriage certificates for spouse, copies of birth certificates for child(ren) and proof of full-time student status for child(ren) over age 19. You must list Social Security numbers for all dependents.

I

CHECK ONE: A(Add), D(De1ete)

CHECK ONE LAT TI ON SHIP

I

1

CHECK ONE

I

DATE OF BIRTH

1

I *NOTE: Your Domestic Partner will not be enrolled in health coverage unless a properly completed application is submitted and

I

approved by Employee Benefits. Please return your completed form to: MTA NYC Transit 180 Livingston Street, Room 6008 Brooklyn, NY 11201-5861

Signature:

OFFICE USE ONLY

Date: Received By: Entered By: Verified By:

I

Date Received: Date Entered: Date Verified:

I

I I --I I

Effective Date : 04/01/2007

Revised 01/30/07

I

Attachment B

GHI Retiree Benefit Description Retired Employees under Age 65 and Not Enrolled in Medicare

Hospital Services Inpatient admissions* Emergency room treatment for medical emergency or accidental injury Routine nursery care Care received in outpatient hospital facilities, including minor surgery, chemotherapy, mammography, and PAP smear screening Treatment for mental and nervous disorders* Outpatient chemical dependency treatment Inpatient physical rehabilitation' Organ transplants* Home health care Hospice care Covered up to 120 days per confinement after you pay $50 per admission to a maximum of $240 per person per calendar year Covered in full Covered in full Covered in full

Covered up to 30 days per person per calendar year subject to $50 inpatient deductible Covered up to 60 visits per person per calendar year Covered up to 30 days per person per calendar year subject to $50 inpatient deductible Covered up to $1,000,000 per recipient per transplant. Costs associated with procurement of the organ are covered up to $10,000 per transplant. Covered up to 200 visits per person per calendar year Covered up to 210 visits per lifetime

Pre-ahssxon certificahon requxement For non-emergency hospital admissions, you or your physluan must call GHI CoorQnated Care For emergency a h s s i o n s , the call must be made withtn two busmess days of the admission Fatlure to comply with h s requuement will reduce benefits by $250 per day up to a rnaxmum of $500 per confinement

Medical Services Home and office visits Diagnostic x-ray and lab tests Annual physical In-hospital surgery In-hospital anesthesia In-hospital medical care Out of hospital surgery Well-child care visits up to age 19 Chiropractic- unlimited visits Speech therapy - 16 visits per year Allergy treatment - 16 visits per year Physical therapy - 8 visits per year Outpatient mental health

When using a GHI Participating Provider $15 copayment $15 copayment (when two or more tests are provided on the same day by more than one Provider, you will be responsiblefor only two copayments) $15 copayment Covered in full Covered in full Covered in full $15 copayment $15 copayment $15 copayment $15 copayment $15 copayment $15 copayment $20 copayment

When using a non-network provider: You will be reimbursed according to the out-of-network Type D3 schedule of allowances and the Extended Medical Benefit (EMB). Reimbursement under EMB is subject to a $100 per person per calendar year deductible, 80% of the Mowed Charge, and a lifetime maximum of $100,000 per covered person. You are responsible for paying any difference between the out-of-network reimbursement and the provider's charge.

Medicare-Eligible Retiree Coverage Summary A program that complements your Medicare Part A and Part B benefits

GHI covers the Medicare Part A hospital deductible and coinsurance up to 120 days GHI covers the Medicare Part B deductible and the 20% coinsurance for Medicare allowed service

Attachment' B

HOSPITAL COVERAGE

Admissions for inpatient hospital care are covered up to 120 days of care during each single confinement subject to the following deductible provision: $50 deductible per person per each single confinement $240 maximum deductible per person or family per calendar year Non-Emergency hospital admissions require you or your physician to call GHl's Coordinated Care Department at 1-212-615-4662 (1-800-223-9870 if calling from outside of New York) for preadmission certification before being admitted. For Emergency admissions, you or a member of your family must contact GHI Coordinated care within two business days of the admission. Outpatient treatment for emergency care is covered in full. In addition, you will be covered at 100% of the allowable charge for services performed by an Emergency Room attending physician.

MEDICAL COVERAGE

PARTICIPATING PROVIDERS

You and your covered dependents are entitled to a full range of medical services through a network of participating providers known as the GHI Comprehensive Benefits Plan (CBP). You can visit GHI online at www.qhi.com to find participating providers in your area or call GHl's Answerline at (212) 501-4444. If your participating medical provider refers you to another physician, ask your referring physician to recommend a participating provider. If the physician you are referred to is not a participating medical provider, you will have to pay that physician's full fee and then file for a reimbursement through the Out-of-Network program. Services performed in the hospital (e.g, surgery, in-hospital medical visits) are generally covered in full. For most out-of-hospital services, you will be charged a $15 copayment for homeloffice visits (including outpatient hospital visits). In addition to a $15 copayment for a homeloffice visit, the most the same participating provider may charge you for tests performed on the date of the visit is a $15 copayment regardless of the number of tests performed. If more than one participating provider is seen, the maximum number of diagnostic copayments per date of service is two ($30). Participating providers will collect the copayments directly from you. Example: If on the day of your medical examination by your participating provider one or more diagnostic tests are performed, you will be charged a total of $30 ($15 for the office visit and $15 for the diagnostic tests). Should you visit two participating providers on the same day and they both perform diagnostic tests, you will pay $60 ($30 for two office visits and $30 for diagnostic tests performed by two participating providers on the same day. If you were to visit a third participating provider on the same day and that provider also performs diagnostic tests, you will pay $15 to the third provider for the office visit and nothing to that provider for the diagnostic tests - bringing your total out-of-pocket cost for that day to $75.

NON-PAR1-ICIPATING PROVIDERS

If you do not choose a participating provider for covered services, you must pay the nonparticipating provider the full fee for covered services rendered and then file for a reimbursement under Out-of-Network Care as described below.

Attachment B

OUT-OF-NETWORK CARE

Covered services provided by a non-participating medical provider are reimbursed in accordance with Type D3 Schedule of Allowances and Extended Medical Benefits (EMB) Schedule of Allowances. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 lnqenix schedule. If you or your covered dependents use a non-participating medical provider, you will need to submit a completed claim form to GHI. You may be required to pay the provider in full for treatment at the time of the visit. You will be responsible for paying the medical provider the difference between the provider's charge and the out-of-network reimbursement, in accordance with GHl's allowances and protocols. Claim forms can be obtained by calling the GHI AnswerLine at (212) 501-4444 or via the GHI website at www.ghi.com. You will need your nine-digit certificate number indicated on your GHI Identification Card when calling GHl's AnswerLine. If you have a question regarding your claim reimbursement call the GHI AnswerLine.

Type D3 Schedule of Allowances The Type D3 Schedule of Allowances provides a fixed dollar reimbursement amount based on the particular covered service rendered. The reimbursement is not subject to a deductible, copayment or coinsurance. Extended Medical Benefits (EMB) Schedule of Allowances The Extended Medical Benefits (EMB) Schedule of Allowances supplements the Type D3 Schedule of Allowances for covered services. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 lngenix schedule The EMB Schedule of Allowances is reduced by any amount paid under the Type D3 Schedule of Allowances. Then, 80% of the net EMB Allowance is reimbursed after satisfaction of a $100 per person deductible* up to a lifetime maximum of $100,000 per covered person.

i

The following examples show reimbursements for a member after satisfaction of the deductible.

$15 Plus $84 = $99

$192 Plus $726.40 = $918.40

$17 Plus $66.40 = $83.40

*Based on 8oth percentile of the 2005 lngenix schedule for the county of Queens, NY. Please note, the lngenix schedule is developed using data by geographic area and therefore will differ by geographic area. Each person is responsible for the first $100 of covered expenses incurred in a Calendar Year based on the allowed charge remaining after being processed under the Type D3 Schedule of Allowances.

Attachment B

OUT-OF-NETWORK CARE

Covered services provided by a non-participating medical provider are reimbursed in accordance with Type D3 Schedule of Allowances and Extended Medical Benefits (EMB) Schedule of Allowances. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 lnqenix schedule. If you or your covered dependents use a non-participating medical provider, you will need to submit a completed claim form to GHI. You may be required to pay the provider in full for treatment at the time of the visit. You will be responsible for paying the medical provider the difference between the provider's charge and the out-of-network reimbursement, in accordance with GHl's allowances and protocols. Claim forms can be obtained by calling the GHI AnswerLine at (212) 501-4444 or via the GHI website at www.cthi.com. You will need your nine-digit certificate number indicated on your GHI Identification Card when calling GHl's AnswerLine. If you have a question regarding your claim reimbursement call the GHI AnswerLine. Type D3 Schedule of Allowances The Type D3 Schedule of Allowances provides a fixed dollar reimbursement amount based on the particular covered service rendered. The reimbursement is not subject to a deductible, copayrnent or coinsurance. Extended Medical Benefits (EMB) Schedule of Allowances The Extended Medical Benefits (EMB) Schedule of Allowances supplements the Type D3 Schedule of Allowances for covered services. The EMB Schedule of Allowances is based on the 8othpercentile of the 2005 l n ~ e n i x schedule The EMB Schedule of Allowances is reduced by any amount paid under the Type D3 Schedule of Allowances. Then, 80% of the net ElVlB Allowance is reimbursed after satisfaction of a $100 per person deductible* up to a lifetime maximum of $100,000 per covered person. The following examples show reimbursements for a member after satisfaction of the deductible.

$15 Plus $84 = $99

$192 Plus $726.40 = $918.40

$17 Plus $66.40 = $83.40

*Based on 8oth percentile of the 2005 lngenix schedule for the county of Queens, NY. Please note, the lngenix schedule is developed using data by geographic area and therefore will differ by geographic area. Each person is responsible for the first $100 of covered expenses incurred in a Calendar Year based on the allowed charge remaining after being processed under the Type D3 Schedule of Allowances.

Attachment C

HTP/VIIP Disenrollment Form

Last Name: First Name: Medicare #:

Sex:

Middle Initial Birth Date:

0M

F

Home Phone Number:

If you request disenrollment, you must continue to receive all medical care from HIP Health Plan until the effective date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of H P Health Plan's network. I We will notify you of your effective date after we have received this form from you. Please carefully read and complete the following information before signing and dating this disenrollment form: On the effective date of enrollment in another Medicare Advantage or Medicare Prescription Drug Plan, I understand Medicare will automatically cancel my current membership in HIP Health Plan. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and do not enroll in such coverage at this time, I may have to pay a higher premium for this coverage in the future. Your Signature*:

\

Date:

*Or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides. If signed by an authorized individual (as described above), this signature certifies that: I) this person is authorized under State law to complete this disenrollment and 2) documentation of this authority is available upon request by HIP Health Plan or by Medicare. If you are the authorized representative, you must provide the following information:

Name: Address: PhoneNumber: ( ) Relationship to Enrollee

-

HP Health Plan is an HMO with a Medicare Advantage Contract I

PLEASE DO NOT STAPLE

Meil canploted & i i f m to: o

New Claim Form

&Y 101182827

APPROVED OMB0938-0008

41

?A'

G

IN THIS

ARFL

'

Attachment D

2

? =

a OTHER INSUREZS POLICYOTI GROUP NUMBE~~

2

E?t?LQYt4ErjT? (CUflREN I Of1 1'11EVIOUS)

0"""C)"O

a. INSURED'S DATE GC BIRTH

O. AUTO ACCIDE&'I?

? W E (SMie)

0"" 0 "

c OTHER MCIDENT?

L

J

( 1011. RCSEFi\lEO FBFt LCK:&

I

U

YES

t' ;

NO

d. 1 THERE APlOTHEFr MfALTN BEMEFITPLAN? 9

USE

(RPPRO'JED BY AAFlA COUNCIL M 4 MEDICAL SERVICE 8/88)

FaRU HCFA-I L E (12-90) % FORM OWCP-1SW FORM RRB-1500

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS I s s u t v ar APPLICABLE PROGRAMS. NOTICE: Any person who knowingly flles a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject t o civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient's signature requests that payment be made and authorizes releaseaof any information necessary to process the claim and certifies that the informationprovided in Blccks 1 through 12 is true, accurate and complete. In thecase of a Medicare clairn, the patient's signature authorizes any entity to releaseto Medicare medical and nonmedical information, including employment status, and whetherthe person has employer group health insurance, liability, no-fault, worker's compensztlon or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42 CFR 41 1.24(a). If item 9 is completed, the patient's signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or CHAMPUS participationcases, the physician agrees to accept the charge determinationof the Medicare carrier or CHAMPUS fiscal intermediaryas the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fisc&&armediary if this is less than the charge submitted. CHAMPUS is not a heallh insurance program but ns makes payment for health benefits provided through ~ e r t a i ~ l i a t i o with the Uniformed Services. Information on the patient's sponsor shouldbe provided in those items captioned in "Insured"; i.e., items la, 4, 6, 7, 9, and 11. BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPUER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG) I certify thattheservicesshown on this form were medically indicatedand necessaryforthe health of the patient andwere personallyfurnished by me orwere furnished incident to my professionalservice by my employee under my immediate p a ~ o n a l supervision, except as otherwise expressly permitted by Medicareor CHAMPUS reguhtions. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under the physician's immediate personal supervision by hislheremployee, 2) they must be an integral, although incidental part of acovered physician's service. 3) they must be of kinds commonly fumished irl physician's offices, and 4) the services of nonphysicians must be included on the physician's bills. For CHAMPUS claims, I further certify that I(or any employee) who renderedservices am not an active duty member of the Uniformed Sewices or a civilian employee of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lungclaims, I further certify that the services performed were for a Black Lung-related disorder. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32). NOTICE: Any one whomisrepresentsor falsifies essential informationto receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECIION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by HCFA, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare. CHAMPUS. FECA, and Black Lung ,programs.Authority to collect informationis in section 205(a), 1862.1872 and 1874 of the Social Secarity Act as amended. 42 CFR411.24(a) and 424.5(a) (6), and 44 USC 3101;41 CFR.lO1 er seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.

Attachment D

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibillty. It Is also used to decide if the services and supplies you received are covered by these programs and to insure lhat proper payment is made. The information may also begiven to other providers of services. carriers, intermediaries, medical review boards, health plans, and otherorganlzatlonsor Federal agencies, tor the effective administration of Federal provisions that require otherthird parties payers to pay primary to Federal program, and as otherwise necessary toadministertheseprograms. Forexample.it may be necessarytodiscloseinforrnation about the benefits you have usedto a hospitalor doctor. Additional disclosu~es are made through routine uses for intormation contained in systems of records. FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501. titled. 'Carrier Medicare Claims Record,' published in h, te Vol. 55 No. 177, page 37549, Wed. Sept. 12. 1990, or as updated and republished. FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, "Republicationof Notice of Systems of Records." Federal Vol. 55 No. 40, Wed Feb. 28. 1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished. FOR CHAMPUS CLAIYS: pRlNClPLF PURPOSE(S):To evaluate eligibility for medicalcare provided by civilian sources and to issue paymentupon establishment of eligibility and determination that the services/supplies received are authorized by law. W T I N F USF(S1; lnformationfrom claims and related documents may be given to the Dept. of Veterans Affairs. the Dept. of ' ~ e a l t h Human Services andlor and the Dept. of Transportationconsistent with their statutory administrative responsibilitiesunder CHAMPUS/CHAMPVA; to the Dept. of Justice for representationof the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection'agencies,and consumer reportingagenciesin connection wRh recoupment claims; and to Congressional Offices in response ro inquiries made at the request of the person to whom a record pertains. Appropriatedisclosures may be made to other federal, state. local, foreign government agencies, private business entities. and individual providers of care, on matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURFS;Voluntary; however, fallure to provide informationwill result in delay in payment or may result in denial of claim. With the one exception discussed below, there are no penalties underthese programsfor refusingto supply information. However, failure to furnish informationregarding themed~cal services rendered or the amount charged would prevent payment of claims under these rograms. Failure to furnish any otherinformation, such as name ordaim number, wwld delay payment of the claim. Failure to provide medical information under R c A could be deemed an obstructioe. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 11288 of the Social Security Act and 31 USC 38013812 provide penalties for withholding this information. You should beaware that P.L. 100-503, the "Computer Matchingand Privacy ProtectionAct of 1988". permitsthegovernmenttoverify informationby way of computer matches. MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept, of Health and Humans Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaidprogram forthose claims submined for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. SIGNATUREOF PHYSICIAN(OR SUPPLIER): I certify that the services listed above were medically indicatedand necessary to the health of this patient and were personally fumished by me or my employee under my personal direction. NOTICE: This is to certify thatthe foregoing information is Irue, accurate and complete. I understandthat payment and satisfactionof this claim will be from Federal and State lunds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecured under applicable Federal or State laws. Public reportingburden for this colleclion of informationis estimated to average 15 minutes per response. including time for reviewing instructions, searching exisling date sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, includingsuggestions tor reducingthe burden, to HCFA. Office of Financial Management. P.O. Box 26684. Baltimore, . MD 21207: and to the Otfice of Management and Budget. Paperwork Reduction Project (OMB-0938-0008).Washington. D.C. 20503. %a + 15006 500M 1zm

(M~rnberIAut~sorized [email protected])

PLEASE READ ALL IIJSTRUGTlO!kd"S

ta: PhamaCare P?Q.Box 2BGQ PifTsbtargh, PA 15236-2860

$m.erts$ mailed brikBB?IPOETAWTIHFORFAATlON BaB3UT YOUR 8LIBlmED GLAl%

" Vifill oniy reimbswe at ihe retali day supply allawanc&.

Will only be reimbursed for rnedizailona covered undsr ?nepias! o medicahona thal already knave Scan ailtnorizsd, r * Submit inis form for reimbursement because it bv,?izsZdcE?GSE?i~ ptkr~n85ga ?m$cripti~ff to wi?sn yoti did not have your jd3fitifica$grt card or because the pharmacy whew your p~scriptiori was f is j is a non-pagicipating pharmacy. (Plar! sp&5c7 pfsasa checi: ri r!

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individuai piarrsf.

* Submil 8 separate ciairn form for each p~tient.

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* ~ i b v lthis S m BE SOOF! as you have your [email protected](~) t a Rlfacl. Claims n a y not be rairnbbmrsed after one p a r , Claim Toms submiti:ed wrinour fne ,%quired infomaiisr: wifi cause payment ds:a.js or msy be [email protected] yoc. b

" If you have any qugstirsns or ccincanls regarding your cklm plcass call :ha moll-free fel~pkorre numbor on yVJi

prescl-igtion identification

FOR CPSPAPDUND FRESZRIPTCONS ONLY If your pham,ncrat. klls yca~ this 1 a compounds3 pre~.;cnplian, s Rave your p ' n ~ m a ~ r ~ t campiere the area 5e!aw Shoutd ycki have morz kherl two wrfipsjndsd prescri-iplions, please u s addiidona! forms.

;PR!vpeaGV gOn13T: Kie wi;l use the address provided zbovc to send ycur,re~mbursernen:, even ifcontrary tc any mnfiaeniiai cornmhinic;litions ins;tru&ons p u may haw2 orr fiiz w& PhamaCa~.1 yau desiig this rzirrm~~r~ernant sen! io a mnfidersfialadcress h a t has previourzly ~ P E O f tc, L E camrnuni&ed to 'PhsmaCar~,please indicate that zcidm~o this fom~ any case, tks address tla: you provide hare wijJ be used aniy for on in maiiifig; related b this Qirec::Wi~4erdtserReimbuwernent.

PRESCRIIPTDON DRUG BENEFIT

PharmaCare's mail service program is administered through PhmCare Direct. The pro_gram is designed d y for those on maintenance medications for the t~eamenr chronic, Iongof term conditions such a - but not Iimited ro - diabetes, arthritis, high blood pressure and s h e m conditions. You wilI receive up t6 a YO-day supply at a time that is delivered directly to your home. A record of p r prescriptions is maintained by PliarmaCare m monitor for u adverse reac&mi with arhcr prescriptions you ,?lay receive horn the mail order or rerail A phmacist wilt conmct your doctor or you before dispensing a new~ork medication if these is cancen? for possible dnrg interactions or adverse reactions.

n a &~emmce ntedEidon yon MUST Direct, P h W s d smeice

(o6gb.d pmdption pius one

1%$UST seat t be o dons sent to PhanmCarc

a a t

to a [email protected]&y sn~"pby. Remember, WU @ e be m &

Gs &

H m ta w e M i d

I.If y o u doctor prescribes a maintemce drug, have it written for up to a 30-day supply wid h e c (3) refills. By Iiavi; a prcscripdor~ ody be, fdled for the quandry can indicared by your doctor and is d i d for one year fsom the date on the pracripuon. 2. If you need medicadon immediately, ask your doctor for w o (2) separate prcxriprions - one ro be fded at a nenvork r e d l pharmcj-, t h e orher to be filled by

mad service.

3. Examine rhe prescription m make sure thac it includes rhe dosage, the doaois

signature, your name, your address and your telephone number. 4. Complete the Codidendal Pauent Profile and EnrolImmr Form. Yo; can obrain this form by conracring PbrnaCare Customer Service ar 866-898-6404. 5. if your meciications zrc not delivered to your home within seven to ten working days call PharmaCare Customer Service. 6 . Order refills by eirher &g h e m toll free a 866-898-6404 mD-Heating t Impaired Number 800-238-0756] or through thet websia at ~ w ~ . P h m a C ~ . c o r n as noted in the fusr paragraph of dlis section. Be prepared to provide your: =mber ID number

prauiption numtcr(s) your credir czrd information Papep1bs Y E h X . Make O X 4 2a Plan copayrnents' (if applicable) Cost of mediations not covered llnder your prescription drug p r o p * Cost of a p m ~ i p t i o n when you use an our-of-nerwork pharmacy .

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