Resource Center
If you have both this group coverage and Medicare, federal rules determine which plan pays first. These rules apply to the working aged, the disabled, or patients with end stage renal disease (ESRD). For The working aged and disabled, these rules take into consideration and employment status of the employee covered by the employer group health plan as well as the number of part-time and full-time employees of the employer group health plan.
If your employer or group employs 20 or more employees and you are 65 years or older and eligible for Medicare only because if your age, this coverage will pay before Medicare, as long as your coverage is based on your status as a current active employee or the status of your spouse as a current active employee.
If your employer or group employs 100 or more employees and if you are under 65 years and eligible for Medicare only because of a disability (and not ESRD), this plan pays first before Medicare as long as your group coverage is based on your status as a current active employee, or the status of your spouse as a current active employee, or the current active employment status of the person for whom you are a dependent.
If you are under age 65 years and eligible for Medicare only because of end-stage renal disease (ESRD), coverage under this plan is not applicable since we do not cover end-stage renal disease or related treatment including dialysis.
When Medicare is allowed by law to be the primary payer, coverage under this plan will be reduced by the amount paid by Medicare for the same covered services. Benefits under this plan will be paid up to either the Medicare-approved charge for services by a Medicare participating provider, or the lesser of our eligible charge or the limiting charge (as defined by Medicare) for services rendered by a provider who does not participate in Medicare.
If you are entitled to Medicare benefits, we will begin paying benefits after all Medicare benefits, including all lifetime reserve days are exhausted.If you have coverage under Medicare Part B only, we will pay inpatient benefits based on our eligible charge less any Medicare Part B benefits for inpatient diagnostic, laboratory and radiology services.
When services are rendered by a provider or facility that is not eligible or entitled to receive reimbursement from Medicare, and Medicare is entitled by law to be the primary payer, we will limit payment to the amount that would have been payable by Medicare had the provider or facility been eligible to receive such payments, regardless of whether or not Medicare benefits are paid.
If you and/or your spouse has Medicare coverage (either Part A or Part B), please be sure to notify NetCare’s Customer Service Department as soon as possible. This will ensure that proper coordination of benefits.
General Guidelines of COBRA Continuation Coverage Rights
Rev.06/04
Federal law requires employers with 20 or more employees to offer temporary continuing healthcare coverage in some cases when an employee’s group coverage ends.
This guideline contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage. This guideline generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. This notice gives only a summary of your COBRA continuation coverage rights. For more information about your rights and obligations under the Plan and under federal law, you should either review the Plan’s Summary Plan Description or get a copy of the Plan Document from the Plan Administrator.
The Plan Administrator is your employer or your employer may have assigned this responsibility directly to NetCare. The Plan Administrator is responsible for administering COBRA continuation coverage.
COBRA Continuation Coverage
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this notice. COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happens:
- Your hours of employment are reduced, or
- Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens:
- Your spouse dies;
- Your spouse’s hours of employment are reduced;
- Your spouse’s employment ends for any reason other than his or her gross misconduct;
- Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or
- You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens:
- The parent-employee dies;
- The parent-employee’s hours of employment are reduced;
- The parent-employee’s employment ends for any reason other than his or her gross misconduct;
- The parent-employee becomes enrolled in Medicare (Part A, Part B, or both); or
- The parents become divorced or legally separated; or
- The child stops being eligible for coverage under the plan as a "dependent child."
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred, When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs. You must send this notice to: NetCare Life & Health Insurance Company, 424 West O’Brien Drive,Suite 107, Hagatna, Guam 96910
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, enrollment of the employee is Medicare (Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage lasts for up to 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended:
-
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled at any time during the first 60 days of COBRA continuation coverage and you notify the Plan Administrator in a timely fashion, you and your entire family can receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. You must make sure that the Plan Administrator is notified of the Social Security Administration’s determination within 60 days of the of the determination and before the end of the 18-month period of COBRA continuation coverage.] This notice should be sent to: NetCare Life & Health Insurance Company, 424 West O’Brien Drive, Suite 107, Hagatna, Guam 96910. -
Second qualifying event extension of 18-month period continuation coverage
If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family can get additional months of COBRA continuation coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent children if the former employee dies, enrolls in Medicare (Part A, Part B, or both), or gets divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. In all of these cases, you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event. This notice must be sent to: NetCare Life & Health Insurance Company, 424 West O’Brien Drive, Suite 107, Hagatna, Guam 96910.
If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact your Human Resources Department or NetCare Life & Health Insurance Company, Group Administration Department at (671) 472-3610 or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’S website at www.dol.gov/ebsa.
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
COBRA Enrollment FormPrescription Drug Information
NetCare members have access to pharmacies on Guam, Saipan, Hawaii and the Continental United States through the OPTUMRX Pharmacy Network. Regular prescription drug co-payments will apply when accessing participating pharmacies.
To locate a pharmacy closest to you on Guam, CNMI, Hawaii or the Continental U.S., please call the OPTUMRX Customer Service toll free number at 1-877-559-2955. The pharmacy will need the numbers listed on the back of your member identification card in order to process your prescription electronically. For additional information, you can log on to www.optumrx.com
What is the Preferred Product List (PPL)?
The Preferred Product List is a list of the most common brand and generic prescription medications available at participating pharmacies. This is an abbreviated list and does not include every medication. All generics are covered at the First Tier whether listed or not. All brand medications are listed in the Second Tier; all non-preferred or non-formulary drugs are listed under the Third Tier; and all injectibles are listed under the Fourth Tier. This list is subject to change based on the review and recommendation of the OPTUMRX independent review committee meedt regularly to consider new and existing prescription medications for inclusion in the PPL.
For further information on your prescription coverage, please refer to your Summary of Plan Description or Summary of Benefits. For questions about product status or if the product does not appear on the PPL, please call OPTUMRX Customer Service at 1-877-559-2955 Toll Free, 24 hours a day, 7 days a week.
What is the difference between brand name, generic medications, and non-formulary or non-preferred drugs?
A generic medication is a copy of a brand-name medication. The color or shape may be difference, but the active ingredients must be the same for both. Generic medications must meet the same quality standards as brand-name medications. A Non-Formulary or non-preferred medication is a drug that is not listed in the Preferred Product List due primarily to the high cost of the drug. The FDA sets these standards and reviews all medications before they are marked. Your coverage for brand-name drugs where a generic is available may vary.
Required Information for Drug Processing
The following information is required for the pharmacy provider to process your prescription claims:
- Rx Bin: 610127
- Rx PCN: 02330000
- Rx Group: 02330075
**FOR ALL PRESCRIPTION DRUG PRIOR-AUTHORIZATION REQUESTS, PLEASE CALL THE OPTUMRX CUSTOMER SERVICE LINE AT 877-955-2955 (AVAILABLE 24-HOURS/DAY)**
Preferred Product List
Prior Authorization
Quantity Limits on Medications
Specialty Drugs
The OPTUMRX Preferred Products List is updated monthly. To access the most recent PPL and for further information, please visit www.optumrx.com
Specific Prescription Policy Changes
Angiotensin Receptor Blockers 1
Angiotensin Receptor Blockers 2
Antihistamines 1 Daily
Antihistamines 2 Daily
Finasteride DACON
Lexapro DACON
Nasal Steroids QL 2 per Month
Plavix DACON
Prescription Formulary
B2B Cycle Premium Formulary Exclusion List
OptumRx July 2024 Premium Formulary Booklet
OptumRx July 2024 Select Formulary Booklet
Transparency in Coverage
The Transparency in Coverage Rule requires health insurers and group health plans to make Machine Readable Files (MRFs) publicly accessible. In response to this requirement, we have links to our In Network and Out of Network MRF files.
The machine readable files (MRF) are formatted to allow researchers, regulators, and application developers to more easily access and analyze data. The links below are updated daily.
PLEASE NOTE: Each MRF is in JSON format and may be as large as one Terabyte (1TB) in file size. Downloading the file could cause significant lag and may result in a system crash if your system does not have the appropriate storage space. Please ensure you have the necessary system requirements before attempting to download.
In Network: Download JSON File
Out of Network: Download JSON File
United Healthcare MRFs can be found here
Can I cancel or enroll in a Dental or Vision Plan at any time?
You may enroll in a Dental or Vision Plan during your initial eligibility period (after you pass your company probationary period) or during the annual open enrollment period of your group. Once enrolled in a Dental or Vision Plan, you may only cancel during the annual open enrollment period of your group or upon termination of employment.
Can I cover my parents if they rely on me for support?
No. Parents are not considered eligible dependents.
Do I need a referral for labs, x-rays and annual eye exams?
No. Referrals are not required for labs, x-rays, annual eye exams performed by an Optometrist (for refraction/eye glasses/contact lenses).
Do I need a referral for medical treatment off-island?
This would depend on the type of Plan you are enrolled under. Please call our customer service department for assistance as some Plans require an approved referral from NetCare before accessing medical providers off-island.
Do I need a referral to see a Specialist?
If you are enrolled under the Advantage Plan, you must have a referral to see a Specialist outside of Guam. On Guam you may self-refer to a participating Specialist.
If you are enrolled under the Continental or Kmart HMO Plan, you must have a referral to see a Specialist both on and outside of Guam.
Do I need to notify NetCare if I am going off-island?
NetCare’s residency requirement stipulates that members must reside within the service area for a minimum of 9 months out of the contract period. If you are moving outside of your service area, you can not continue to be covered under the policy. If you are off-island for medical treatment, your treatment will be covered for a maximum of 90 days.
If you elect COBRA coverage and you are moving off-island, you will be covered for a maximum of 90 days.
How can I determine if a doctor or hospital is a participating provider?
You may request a copy of our printed Participating Healthcare Provider Directory, or you may view our list of participating providers on this website. To locate a participating provider in Micronesia, Philippines, Asia, Hawaii and the Continental United States, please:
- Call our customer service department at (671) 472-3610
- Log on to www.firsthealth.com to locate participating medical providers in the Continental United States (does not apply to providers in Hawaii)
- Log on to www.prescriptionsolutions.com to view participating pharmacy providers in the Continental United States and Hawaii.
How can I file a request for reimbursement?
You must complete a request for reimbursement form and submit all supporting documents including a claim form completed by your physician’s office and original receipts showing proof of payment. All non-English claims must be translated into English (detailed, indicating all services rendered). Requests for reimbursement for prescription drugs must include the label issued by the pharmacy and medical notes.
Dental claims must include a claim form (or detailed medical notes and tooth chart if services were rendered in the Philippines). Claims must be submitted to the NetCare office within 90 days of the date of service with all required documents. NetCare will not request documents for members. Reimbursements will be paid within 45 business days.
I received a statement in the mail. How do I know if NetCare paid my claim(s)?
You can view your paid claims on the NetCare website. Click on "Member", 'Member' again, then you will be asked to enter or create your ‘User Name’ and ‘Password’. Once in your eligibility screen you can view your paid claims.
Up to what age may I cover my dependent children?
- Eligible children may be covered up to age 25.
- Eligible children ages 19 - 25 who reside outside the service area for secondary schooling may be covered up to the attainment of age 25. A Student Verification must be submitted every semester to maintain coverage outside the service area.
- If you have been granted legal guardianship of a minor child, that child may be covered up to the attainment of age 18.
- Eligible children who have been certified as disabled by a physician may be covered past the age of 19.
What do I do if I have a baby and would like to add the baby to my health insurance?
A newborn baby is NOT automatically added to your policy. You will need to submit a Change of Status Form along with a copy of the Birth Certificate (from the hospital or from Public Health) to your Human Resources office as soon as possible, but no later than 30 days from the baby’s date of birth.
What do I do if I have an emergency (on or off-island)?
Please proceed to the nearest hospital emergency room or urgent care center. Bonafied emergencies (the sudden and unexpected onset of a severe medical condition, which if not treated immediately would be life threatening or result in permanent disability) are covered at any medical facility (subject to the emergency co-payment and limitations of your Plan).
What do I do if my name or address changes?
You will need to submit a Change of Status From (and supporting documentation for name changes such as a Marriage Certificate) to your Human Resources Office. Once NetCare has received a copy of the Change of Status Form we will update your information in our system. It is very important to keep NetCare informed of any address changes as periodically we mail important information to members about their health benefits.
What else can I view on the NetCare Website?
As a NetCare Subscriber, you have access to easy and powerful web service 24 hours a day. Once in the website, you can view:
- Eligibility status
- Benefits (view your Plan Benefit Sheet & Summary Plan Description)
- Paid Claims & EOBs (Explanation of Benefits)
- Self-help medical and health information
- Participating Providers and provider updates
- Links to FirstHealth CCN Medical Providers
- Link to Prescription Solutions Rx Pharmacy Providers (and personal prescription drug information)
- Newsletters
- Forms
What if my Membership I.D. Card is lost or stolen?
lease call the NetCare customer service department to request replacement cards. You will be charged $2.00 per card.
What is a pre-certification and when is one required?
Pre-certification is the review and approval process by NetCare for certain procedures. The following procedures require pre-certification from NetCare:
- Inpatient confinements
- Skilled Nursing Admissions
- Outpatient elective surgery, including circumcision and sterilization procedures
- Major Diagnostic Procedures such as MRI, CT Scan, Ultrasound, Cardiac Catheterization, Cardiac Angioplasty, Cardiac Stress Test, Biopsy, Bone Scan, etc.
- Home Health Care
- Durable Medical Equipment
Your physician will communicate with NetCare when pre-certification is required.
When will I receive my Membership I.D. Card?
You should receive your NetCare Membership I.D. card within 10 working days from the date your Enrollment or Change of Status Form was submitted. If you have not received your card, please call the NetCare customer service department at 472-3610.
Will NetCare pay for my airfare for off-island medical treatment?
You may qualify for the NetCare airfare benefit if you meet the following criteria:
- You must have a written referral from a participating physician and subsequent approval from NetCare
- The referral must be for a procedure meeting the criteria as set forth by NetCare. Procedures that may qualify for airfare include: Cardiac Surgery, Cardiac Catheterization, Cardiac Angioplasty, Cancer Surgery, Neurosurgery, Gamma Knife Surgery and Radiation Therapy. (Subject to Plan review).
- Treatment/services are rendered at a designated NetCare Center of Care, including: St. Luke's Medical Center, Makati Medical Center, Philippine Heart Center and The Medical City Medical Center in the Philippines, or Anaheim Memorial Medical Center, Good Samaritan Hospital or White Memorial Medical Center in Los Angeles, California.
- Group Premium payments must be current
- If the criteria is met, NetCare will purchase a round-trip ticket (lowest economy fare available) to a Center of Care for the patient only. NetCare will not purchase tickets for escorts (including medical professionals).
- This benefit does not apply to Continental members (PPO or HMO)
Do I need to choose a Primary Care Physician (PCP)?
This would depend on the type of Plan you are enrolled under. If you are enrolled under the Advantage Plan, Continental HMO Plan or Kmart HMO Plan, you are required to choose a primary care physician for each family member enrolled in the Plan. You may change your PCP by calling the NetCare customer service department at (671) 472-3610. You may also email your request to tvillagomez@netcarelifeandhealth.com or vfarnum@netcarelifeandhealth.com. (Please include your daytime contact number in the email.
