2015 dual eligible special needs plan (d-snp) annual ...

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1、January1–December31,2015EvidenceofCoverage:YourMedicareHealthBenefitsandServicesandPrescriptionDrugCoverageasaMemberofMercyCareAdvantage(HMOSNP)ThisbookletgivesyouthedetailsaboutyourMedicareandAHCCCS(Medicaid)healthcareandprescriptiondrugcoveragefromJanuary1–December31,2015.Itexplainshowtogetcovera

2、geforthehealthcareservicesandprescriptiondrugsyouneed.Thisisanimportantlegaldocument.Pleasekeepitinasafeplace.Thisplan,MercyCareAdvantage,isofferedbySouthwestCatholicHealthNetwork.(WhenthisEvidenceofCoveragesays“we,”“us,”or“our,”itmeansSouthwestCatholicHealthNetwork.Whenitsays“plan”or“ourplan,”itme

3、ansMercyCareAdvantage.)MercyCareAdvantageisaCoordinatedCarePlanwithaMedicareAdvantagecontractandacontractwiththeArizonaMedicaidprogram,ArizonaHealthCareCostContainmentSystem(AHCCCS).EnrollmentinMercyCareAdvantagedependsoncontractrenewal.Thisinformationisavailableforfreeinotherlanguages.Pleasecontac

4、tourMemberServicesnumberat602-263-3000foradditionalinformation.(TTY/TDDusersshouldcall711).Hoursare7daysaweekand24hoursaday.MemberServicesalsohasfreelanguageinterpreterservicesavailablefornon-Englishspeakers.Estainformaciónestadisponiblegratisenotrosidiomas.PorfavorcomuníqueseanuestronúmerodeServic

5、iosalMiembroal602-263-3000o1-800-624-3879paramásinformación.(UsuariosTTY/TDDdebenllamaral711.)Horason24horasaldía,7díasalasemana.ServiciosalMiembrotambiéntieneserviciosgratuitosdeinterpretacióndelenguajedisponibleparapersonasquenohablanIngles.Thisdocumentmaybeavailableinotherformatssuchaslargeprint

6、orotheralternateformats.Thisdocumentmaybeavailableinanon-Englishlanguage.Foradditionalinformation,callMemberServicesatthephonenumberlistedabove.Benefits,formulary,pharmacynetwork,premium,deductible,and/orcopayments/coinsurancemaychangeonJanuary1,2015.H5580_15_042CMSAcceptedFormCMS10260-ANOC/EOC(App

7、roved03/2014)OMBApproval0938-10512015EvidenceofCoverageforMercyCareAdvantageTableofContents22015EvidenceofCoverageTableofContentsThislistofchaptersandpagenumbersisyourstartingpoint.Formorehelpinfindinginfor