Page 22 - Commercial Group Member Guidebook

Straight Talk

AT CONNECTICARE, WE BELIEVE IN EXPLAINING THINGS IN PLAIN ENGLISH. WE DO SO
TO HELP YOU BETTER UNDERSTAND THE INS AND OUTS OF YOUR PLAN.

Some care is not covered
Managed care companies decide what care is or isn’t covered by the insurance plan. That’s part of
a managed care company’s job in trying to control costs. Our decisions are made by doctors and
nurses with input from members, physicians and other health care practitioners. Sometimes, even
services you think should be covered are not paid for by your plan. Your plan’s exclusions are listed
in the “Exclusions” and/or the “Non-Covered Services” sections of the applicable plan’s Membership
Agreement/Certificate of Coverage. And, if we have determined that a service is not medically
necessary, you have the right to appeal in accordance with the terms of your plan.

The cost of care matters
Managed care companies are in the business of trying to control health care costs. The cost of a
service is considered when making coverage decisions. For example, if there is a less expensive,
but equally effective or less invasive treatment available than the treatment that is being proposed,
we will consider the cost in determining whether to cover the proposed treatment. Cost isn’t the only
criteria we consider, but input from members and doctors is obtained to make these decisions.

Drug costs matter
Our tiered system places drugs in categories that tell you what your cost-share will be for that drug.
If a covered drug is in a higher tier, that doesn’t mean it’s not a good drug or that you shouldn’t get it.
It just means that you will have to pay a higher cost for it. Sometimes, there might be an equally
effective generic or alternative drug on a lower tier that you can use. Other times you and your
doctor will decide that you need to have the drug on the higher tier. But in any case, you can get the
drug — you just may have to pay a higher cost for it.

You have to use participating practitioners in HMO Plans
As you know, HMOs operate by using a network of participating practitioners and provider facilities.
That means that you have to use a participating practitioner in the network to get your care covered,
even if you feel that a non-participating practitioner is a “better” doctor for you or you prefer to use a
non-participating practitioner.

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