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Medicaid is a program for people with low income who meet certain eligibility requirements and programs can vary from state-to-state. Medicare is a federal health insurance program for people who are age 65 or older, disabled persons, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.
When you apply for Medicaid, you must fill out an application form. You will also need to have various documents:
The Explanation of Benefits is a document you will get each month you use your prescription drug coverage. It will tell you the total amount you have spent on your prescription drugs and the total amount we have paid for your prescription drugs. You will get your Explanation of Benefits in the mail each month that you use the benefits that we provide.
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. Hours of Operation: 8 A.M to 5 P.M., Monday – Friday during your time zone.
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.
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.
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.
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. Calls to this number are free. 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.
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.
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.
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.
When you return home, simply submit your claim and your receipt to the following address:
P.O. Box 6082
Cypress, California 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.
A formulary is a list of covered drugs provided by the Plan. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage.
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.
You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. You may also get updated information about the drugs covered by us by visiting our Website.
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.
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.
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.
"Covered drugs" means all of the outpatient prescription drugs that are covered by our Plan. Covered drugs are listed in our formulary.
If you have a medical emergency:
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.
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.
Medicaid Managed Care
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