Understanding Your Benefits

What every member should know

To get the most from your plan, know the answers to these basic questions:

What makes up your contract and what it tells you?
What are your benefits and how to use them?
What you pay for services?

Your contract and what it tells you

All the details on covered services can be found in your contract.

The table below identifies all documents which make up the contract and the information each one provides.

Document	information it provides
Certificate of Coverage	describes your benefits in detail and gives requirements, limitations and exclusions for coverage.
Outline of Coverage	what you must pay in co-payments, deductibles, coinsurance, etc. lists services that require prior approval, and phone numbers to call to get review
Riders or Endorsements (listed on outline of coverage)	additional coverage or, changes to your contract
ID Card	portable proof of coverage show it to your provider and pharmacy to receive benefits

Benefits

Defintion

The term "benefit" refers to any service (examples: office visits, surgical procedures) or supply (example: prescription drugs) covered by your health plan.

What are my benefits?

To find out what your specific benefits are, consult your contract.

How to use them?

To use your benefits properly you should verify coverage before you receive services. This will help you determine:

if a service/supply is covered under your health plan
any requirements you must provide to receive a service/supply
the cost you may pay for a particular service/supply

Present your ID card before you receive services.

What you pay for services

In addition to your monthly premium, you are responsible for paying a portion for services received. Your plan will consist of one, or a combination of the following out-of-pocket expenses: