MMC Benefits Handbook
Is there a network of doctors and hospitals that I have to use?
Using the network is not mandatory, but generally, you will receive a higher reimbursement when using the network. If you use an in-network provider, you will be reimbursed 80% (70% under the $2,850 Deductible Plan). If you use an out-of-network provider, you will be reimbursed 60% (50% under the $2,850 Deductible Plan) of reasonable and customary charges for covered expenses after the Plan's deductible has been met.
In the event that you receive care from an out-of-network doctor (such as an anesthesiologist) while being treated at an in-network facility, benefits will be paid at the in-network level.
The network includes general practitioners, as well as specialists and hospitals. These network providers are selected by and contracted with the Claims Administrator.
Depending on the geographic area and the service you receive, you may have access through UnitedHealthcare's Shared Savings Program to non-Network providers who have agreed to discounts negotiated from their charges on certain claims for Covered Services. Shared Savings is a program in which UnitedHealthcare may obtain a discount to a non-Network provider's billed charges. This discount is usually based on a schedule previously agreed to by the non-Network provider. When this happens, you may experience lower out-of-pocket amounts. Plan coinsurance and deductibles would still apply to the reduced charge. Sometimes Plan provisions or administrative practices conflict with the scheduled rate, and a different rate is determined by UnitedHealthcare. In this case the non-Network provider may bill you for the difference between the billed amount and the rate determined by UnitedHealthcare. If this happens you should call the number on your ID Card.
Important Information about Network Providers
UnitedHealthcare is your Claims Administrator if you live within the United States, except if you live in Massachusetts, Maine and New Hampshire. Harvard Pilgrim Health Care network is the Claims Administrator if you live in Massachusetts, Maine and New Hampshire.
You must access a UnitedHealthcare Network Provider in order to receive the Network level of benefits.
Where can I get a directory that lists all the doctors and hospitals in the network?
The doctors and hospitals in the network are listed in a provider directory. The Claims Administrator provides an online directory of providers available at www.myuhc.com. You may also call the Claims Administrator.
Is there a network of providers for mental health treatment?
There is a network of mental health providers. Providers in the network are listed in a provider directory. The Claims Administrator provides an online directory available at www.myuhc.com. You may also call the Claims Administrator.
Is there a network of pharmacies?
There is a pharmacy network associated with this Plan. You must use a pharmacy in the network to receive coverage under this Plan.
The Pharmacy Benefits Manager provides an online directory of network pharmacies available at http://www.express-scripts.com/.
To locate an in-network retail pharmacy:
- Log on to express-scripts.com.
- Login or create an account.
- Locate a pharmacy.
Or call Express Scripts at +1 800 987 8360 for more information.