On the Internet

At VISTA’s web site www.vistahealthplan.com you can:

• Review and print your plan documents, including your Schedule of Benefits, Certificate of Coverage (COC), and any applicable riders and amendments, which explain your benefits and payment responsibilities.
• Request a change in your primary care physician (PCP), if applicable.
• Request an ID card and print a temporary ID card.
• Find a participating physician, specialist, hospital, pharmacy or urgent care center.
• Contact VISTA with a question or suggestion or to report a problem.
• Request forms and literature, such as a Provider Directory, plan documents, list of formulary medications, or Reimbursement Form.

New features are added to the web site regularly.

By telephone

• Call Customer Service at the number listed on your ID card, which is 1-866-VISTA-FL (1-866-847-8235).

If you have a hearing or speech impairment and use a TDD (telecommunication device for the deaf) call 1-888-444-7352.

Service is available 24-hours a day, 7-days a week through the Interactive Voice Response (IVR) system. You can:

• Verify eligibility.
• Request an ID card.
• Check your copayments, deductibles and maximum out-of-pocket amounts (when applicable).
• Request forms and literature, such as a Provider Directory, plan documents, list of formulary medications, or Reimbursement Form.

If you need to speak with someone, Customer Service representatives are available to assist you Monday through Friday from 8 a.m. to 6 p.m. Representatives are available who speak English and Spanish and a translation line is used for other languages.

By fax

VISTA’s Customer Service fax number is 954-846-8873.

Send Correspondence to

In person

The South Florida Customer Service walk-in unit is open Monday through Friday from 8:30 a.m. to 5:30 p.m. It is located in VISTA’s Sunrise office at 1340 Concord Terrace, Sunrise, FL 33323. Listed below are contact numbers for questions about specific benefits that may apply to your plan:

Prescription drugs VISTA Pharmacy Services at 1-866-VISTA-RX (1-866-847-8279), Monday through Friday from 8:30 a.m. to 5:30 p.m.

Dental benefits Dental Customer Service at 1-800-848-3480, Monday through Friday from 8 a.m. to 6 p.m.

Vision benefits VISTA Customer Service at 1-866-VISTA-FL (1-866-847-8235), Monday through Friday from 8 a.m. to 6 p.m.

2.1 Your Member Identification Card

You will receive a VISTA member identification (ID) card for yourself and each enrolled dependent. Present this card to the health care provider whenever you seek medical services or to the pharmacy when filling a prescription. The card has the information the provider or pharmacy needs to verify your benefits and bill VISTA for the services you receive. Take it with you when you travel in case of an emergency.

If you or one of your enrolled dependents did not receive an ID card, or if a card is lost, you can request a new one online at VISTA’s web site, by calling the Interactive Voice Response system (IVR), or by speaking with a Customer Service representative. A temporary ID card can be printed from VISTA’s web site.

Your ID card contains the name and office telephone number of your primary care physician (PCP)*. It also shows your copayments for common services, such as PCP and specialist office visits, emergency room and urgent care center visits, and prescription drugs, if your plan includes a prescription drug benefit.

It is possible that the PCP listed on your ID card is different from the one you selected when you completed your enrollment application. There are various reasons for this. The PCP you chose may no longer be participating with VISTA, or he or she is no longer accepting new patients. If you prefer a different PCP than the one listed on your ID card, you may call Customer Service or visit the web site to request a change. (refer to section “Changing your Primary Care Physician”).

*Note: Choice and Value Open Access POS members are not required to select a PCP.

2.2 What is an “HMO”?

The health benefits plan your employer has purchased is a health maintenance organization or “HMO” plan. HMO plans offer comprehensive health benefits, including preventive care services. Most members have a standard HMO plan, which means you must use physicians and other health care providers who participate in the plan’s provider network to receive covered services. Exceptions to this are emergency services and care or when the out-of-network services are approved by the HMO in advance. There are other types of HMO plans with variations from the standard HMO plan, which are explained in this Member Handbook.

2.3 Types of HMO Plans

Some employers have purchased VISTA HMO plans that have variations from the standard HMO copay plan. The variations are Point of Service (POS) plans, Open Access or Open Access Plus plans, Focused Deductible plans or Focused Deductible Coinsurance plans, High Deductible Health Plans (HDHMO) and Health Savings Accounts (HSA) and Health Reimbursement Arrangement (HRA)-Compatible Health Plans.

2.4 Your Plan’s Service Area

As a VISTA HMO member you can receive covered services only in the designated service area for your benefits plan, unless the services are for an emergency medical condition or are approved by VISTA in advance*.

The service area for your health benefits plan is:

In North Florida: Alachua, Bradford, Calhoun, Columbia, Dixie, Escambia, Franklin, Gadsden, Gilchrist, Hamilton, Jefferson, Lafayette, Leon, Levy, Liberty, Madison, Marion, Santa Rosa, Suwanee, Union, and Wakulla counties.

In South Florida: Broward, Miami-Dade, Palm Beach, Martin and St. Lucie counties.

*NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS plan members may choose to receive services from a non-participating provider outside the service area. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

2.5 What are Covered Services?

Covered Services are medically necessary services of health care professionals or other providers, including medical, surgical, psychiatric, diagnostic, therapeutic and preventive services and supplies specified in the covered services section of the Certificate of Coverage, listed on the Schedule of Benefits or any rider, amendment or endorsement of your plan documents. Covered services are subject to specific limitations and exclusions. If you have questions regarding whether a service is a covered service, contact Customer Service by calling the toll-free number on your ID card.

2.6 What is a Participating Provider?

A participating provider is any physician or health care professional, organization, supplier or health care items, or a health care facility having a written contract at the time services were provided with VISTA to provide medical services to a VISTA member.

A list of participating providers can be found in your VISTA Provider Directory. If you need a current copy of the directory, please call Customer Service. There is also an up-to-date listing of participating providers on VISTA’s web site. Because directory information is subject to change, when you make an appointment make sure that you ask your provider if he or she is a participating provider with VISTA. Also, you should ask if the provider is accepting new patients (if you are not already a patient of this provider).

2.7 A Primary Care Physician (PCP)

When you enroll in certain VISTA HMO plans, you must choose a primary care physician (PCP), from VISTA’s Provider Directory or VISTA’s web site. A PCP is a physician (licensed under Chapter 458, 459, 460 and 461 of the Florida Statutes) who has a written contract with VISTA to be primarily responsible for the overall medical care of a Member, including, but not limited to, any referral to a Participating Provider. Not all HMO plans require choosing a PCP, however VISTA encourages each Member to select a PCP to be responsible for providing and managing their primary health care. Check your plan documents for benefit details*.

*Note: Choice and Value Open Access POS members are not required to select a PCP.

2.8 Choosing a Primary Care Physician

When choosing a PCP*, consider your individual needs. Careful PCP selection minimizes the need for change, which could disrupt continuity of care. Here are a few factors to consider when choosing a PCP:

• Location – is the physician’s office conveniently located? Would you prefer an office located near where you live or where you work? If traveling by mass-transit, is there a bus stop nearby?
• Specialty – would an internal medicine physician or family practitioner best suit your needs? If selecting a PCP for your child, would a pediatrician or family practitioner be best?
• Medical group or independent practice – is the physician a member of a medical group or in independent practice?
• Hospital affiliation – does the physician admit patients at the participating hospital that you prefer?
• Language -can the physician (or a staff member) communicate in the language that you speak and understand?

*Note: Choice and Value Open Access POS members are not required to select a PCP.

2.9 Changing your Primary Care Physician

You may change your PCP* for any reason at any time. Refer to your Provider Directory, or VISTA’s web site to select a new PCP that meets your needs. You can request the change on the web site at www.vistahealthplan.com, or you can call Customer Service. Customer Service can help you select a new PCP and will make sure that the PCP you select is accepting new patients.

PCP changes will be effective on the first day of the next month. For example, if you request a change on any day in January, the change will be effective on February 1st.

After you make the change you will receive a new ID card showing the name and office telephone number of your new PCP.

*Note: Choice and Value Open Access POS members are not required to select a PCP.

2.10 Receiving Care from your Primary Care Physician

If you are not already a patient of the PCP, we encourage you to make an appointment to see your new PCP as soon as possible so he or she can get to know you and your health care needs. In addition to providing much of your care, your PCP will help arrange or coordinate the covered services you receive. This includes X-rays, laboratory tests, therapies, specialist office visits, hospital admissions and follow-up care. If you need certain types of covered services or supplies, your PCP must arrange for them in advance (such as giving you a referral to see a specialist)*. In some cases, your PCP will also need to get prior authorization from VISTA. Since your PCP will provide and coordinate your medical care, you should have all of your medical records sent to your new PCP’s office.

*NOTE: Open Access, Open Access Plus, Focused Deductible Open Access, Focused Deductible Open Access Plus, HDHMO, Focused Deductible Coinsurance Open Access, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS

members do not need a referral from their PCP to receive covered services.

2.11 What happens if you see a PCP other than the one you selected?

Developing an ongoing relationship with one physician is important for the effective delivery of your health care. Should you visit a PCP other than the one printed on your ID card, VISTA will not pay for services you receive from that physician*.

*NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may choose to see any non-participating physician, subject to certain exclusions listed in your plan documents. If you see a non-participating physician, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents. Choice and Value Open Access POS members are not required to select a PCP.

2.12 If you have a Medical Emergency

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

• Serious jeopardy to you, including a pregnant woman or fetus;
• Serious impairment of bodily functions; or
• Serious dysfunction of any bodily organ or part.

For women that are pregnant, emergencies are when:

• There is inadequate time to effect safe transfer to another hospital prior to delivery;
• A transfer may pose a threat to the health and safety of the patient or fetus; or
• There is evidence of the onset and persistence of uterine contractions or rupture of the membranes.

If you have an emergency medical condition and you are in the service area, you should contact your PCP if possible. If you cannot contact your PCP, you should dial 911 for immediate help, or go directly to the nearest emergency room, hospital, or participating urgent care center. If you are out of the service area, you should dial 911 for immediate help, or go directly to the nearest emergency room, or hospital.

If you obtain services through an emergency room, VISTA encourages you, or someone on your behalf, to notify your PCP within 48 hours of the emergency room visit, or as soon as reasonably possible so that your PCP can coordinate your follow-up care.

Once you are discharged from the Emergency Room or the hospital, remember to schedule all follow-up care with your PCP. Even if the emergency room physician instructs you to return to the hospital for follow-up, you should check with your PCP first. Failure to coordinate follow-up care with your PCP will result in denied claims, and you will be responsible for payment*.

*NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may choose to receive follow-up care from a non-participating provider, subject to certain exclusions listed in your plan documents. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

Please note: your claim may be denied if you go to the emergency room for services other than emergency medical conditions.

2.13 What is Urgent Care?

Urgent care is medically necessary care for an unexpected illness or injury that does not qualify as an emergency medical condition but requires prompt medical attention. Your physician can help you determine whether or not you need to receive urgent care at an urgent care facility. Some examples of urgent care cases are:

• Sprains
• Non-severe bleeding
• Simple cuts that require stitches

If you have an unexpected illness or injury while in the service area that requires immediate treatment, call your health care provider. He/she will be able to advise you what to do.

If you have an unexpected illness not usually associated with urgent care while you are out of the service area, VISTA may pay for treatment at an urgent care facility. For urgent care outside the service area, please call Customer Service to obtain specific benefit information.

2.14 After-Hours Care

If you develop an urgent health problem after office hours or on the weekend, you should call your physician, unless your health condition is an emergency medical condition. In the case of an emergency medical condition, please go to the nearest emergency room or call “911” immediately. All VISTA network health care providers are committed to providing coverage 24 hours a day, 7 days a week. There will always be a physician on call to help you.

2.15 Receiving Care outside the Service Area

Your benefit plan’s service area is defined in the section “Your Plan’s Service Area.” If you need care when you are outside the service area, your coverage is generally limited to emergency services and care*. If you have questions about what medical care is covered when you travel, please call Customer Service.

*NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may choose to receive services from non-participating providers outside the service area, subject to certain limitations listed in your plan documents. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

2.16 Receiving Care from Specialists

If your PCP decides you need specialized treatment, he or she will give you a referral to see a participating specialist*. A specialist is any health care professional duly licensed to practice medicine or osteopathy in the State of Florida and to whom a Member has been referred by a PCP with a written referral form.

VISTA does not take part in reviewing and/or approving referrals to participating providers.

It is very important to get a referral from your PCP before you see a specialist (there are a few exceptions that are explained in the section “Direct Access Services”). If you do not have a referral before you receive services from a specialist, you will have to pay for these services. If the specialist wants you to return for additional care, check with your PCP to be sure that the referral you received covers additional visits.

*NOTE: Open Access, Focused Deductible Open Access, HDHMO, Focused Deductible Coinsurance Open Access and Choice and Value Open Access POS members may go directly to a participating specialist without first obtaining a referral from their PCP.

Open Access Plus, Focused Deductible Open Access Plus, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may go to a participating or non-participating specialist without a referral, subject to certain exclusions listed in your plan documents. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

2.17 Direct Access Services

You may obtain some services, without a referral from your PCP. These services are called “direct access” services. You must use a participating provider* and pay the applicable copayment. These providers are listed in the “Direct Access” section of the HMO Provider Directory and your Certificate of Coverage.

• OB/GYN annual well woman exam.
• Preventive and primary care services from the Member’s PCP.
• Chiropractic services for non-surgical treatment of spine and back disorders.
• Podiatry services.
• Refractive eye exams from a participating Optometrist (if applicable).
• Dermatology services (five visits each year for minor procedures and testing).

There is also direct access for all medical services provided by a general GYN and OB/GYN, excluding sub-specialty OB/GYN services.

*NOTE: Open Access, Open Access Plus, Focused Deductible Open Access, Focused Deductible Open Access Plus, HDHMO, Focused Deductible Coinsurance Open Access, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS

members may go directly to all participating specialists without first obtaining a referral from their PCP.

POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may use a non-participating provider for dermatology, chiropractic and podiatry services, but must use a participating provider for wellness care and vision services. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

2.18 Mental Health and Alcohol and Substance Abuse Services

If your benefit plan includes coverage for mental health and alcohol and substance abuse services (refer to your plan documents), you do not need a referral from your PCP to receive care. To arrange services, or if you have any questions about mental health or alcohol and substance abuse services, call the mental health services provider at the number printed on your ID card.

2.19 When Services are not available from a Participating Provider

Although VISTA has contracted with a large network of health care providers, there might be an occasion when your PCP may need to send you to a non-participating provider. A referral to a nonparticipating provider must be approved by VISTA in advance*. Contacting VISTA is the responsibility of your PCP. When VISTA approves your referral to a non-participating provider, you will be responsible for copayments, deductible and/or coinsurance as required by your benefits plan.

*NOTE: Open Access Plus, Focused Deductible Open Access Plus, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may go to a participating or non-participating specialist without a referral, subject to certain exclusions listed in their plan documents. If you see a non-participating provider, you will be responsible for additional costs, such as a deductible and coinsurance, as explained in your plan documents.

2.20 Services that require Prior Authorization from VISTA

Some services require approval in advance, called prior authorization, from VISTA. If prior authorization is not obtained when it is required, certain services may be subject to a penalty or denied*. In most cases, when you receive in-network care, your health care provider will be responsible for obtaining prior authorization for services. You should always show your VISTA member ID card to your provider prior to receiving services. If you use non-participating providers, you are responsible for obtaining prior authorization or making sure that the non-participating provider obtains the prior authorization.

If you receive care from your PCP or through a referral from your PCP, the PCP will obtain any necessary approvals for you. If you have been referred to a specialist, the specialist may obtain the prior authorization. Below is a partial list of services requiring prior authorization. Please call Customer Service for specific requirements as services requiring prior authorization may change.

• Hospital admissions and Skilled nursing Facility admissions;
• All non-emergency outpatient hospital services including but not limited to, surgical, laboratory and diagnostic procedures;
• Non-emergency wound care procedures;
• Durable Medical Equipment – customized/specialty items;
• Braces, prosthetics, orthotics;
• Home health care services
• Hospice care
• Laparoscopic Hysterectomy
• MRI/MRA
• Neuropsychology
• Non-emergent transportation; air ambulance
• Non-participating providers
• Oral surgery
• Pain management
• PET Scan
• Rehabilitative services, inpatient and outpatient
• Sleep Studies

Members are not required to obtain prior authorization before seeking emergency services and care.

Even though your PCP or other participating provider will handle the request for prior authorization when necessary, it is your responsibility to verify prior authorization is obtained. The authorization telephone number is on the back of your ID card.

*NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may have additional member responsibility if prior authorization is not obtained. Prior authorization requirements apply to POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus

and Choice and Value Open Access POS members who are receiving services from nonparticipating providers.

Prior authorization is not a guarantee of coverage. Members must be eligible for coverage at the time the services are rendered.

2.21 Going to a Hospital

Except for emergency services and care, your PCP is responsible for coordinating any necessary hospital care. You, or someone on your behalf, may call Customer Service to ensure that the admitting physician has received prior authorization for your hospitalization. Your PCP or an assigned hospitalist will manage your care, coordinate diagnostic tests and treatment, and plan for your discharge. In addition, VISTA clinical staff will work with your PCP to help coordinate services to maintain continuity of care when you are discharged from the hospital.

2.22 VISTA’s Hospitalist Program

VISTA has introduced a program in most participating hospitals called the Hospitalist Program. The program is staffed by physicians called “hospitalists” whose practice includes caring for VISTA members in the hospital. These physicians coordinate and oversee every aspect of a hospital stay, from admission to discharge. They work closely with your primary care or admitting physician to ensure you receive the care you need while in the hospital. The hospitalist physician does not replace your physician. It is a service your physician may elect to use in the event you are hospitalized. There is no cost to you for the services of a hospitalist physician.

2.23 Your safety when receiving Treatment

Staying safe and avoiding possible medical errors means taking an active role in your health care. VISTA encourages you to follow these five important steps to enhance your safety when receiving treatment in a health care facility.

1. Speak up if you have questions or concerns. Choose a physician with whom you feel comfortable talking about your health and treatment. Take a relative or friend with you if this will help you ask questions and understand the answers. Remember, it is okay to ask questions and to expect answers you can understand.
2. Keep a list of all the medicines you take. Tell your physician and pharmacist about all the medicines you take, including over-the-counter medicines such as aspirin, ibuprofen, and dietary supplements, vitamins and herbal supplements. Discuss any drug allergies you have. Ask the pharmacist about side effects and what to avoid while taking the medicine. When you get your medicine, read the label, including warnings. Make sure it is what your doctor ordered and you know how to use it. If the medicine looks different than you expected, ask the pharmacist.
3. Make sure you get the results of any test or procedure. Ask your doctor or nurse when and how you will get the results of tests or procedures. If you do not get them when expected – in person, on the phone, or in the mail – don’t assume the results are fine. Call your doctor and ask for the results and what they mean for your care.
4. Talk with your doctor about your options if you need hospital care. If you have more than one hospital to choose from, ask your doctor which one has the best care and results for your condition. Hospitals treat a wide range of problems; however, for some procedures (such as heart bypass surgery), research shows results are often better at hospitals that perform a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care.
   1. Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon:
      • Who will take charge of my care while I am in the hospital?
      • What is actually done during the surgery?
      • How long will my surgery take?
      • What will happen after the surgery?
      • How can I expect to feel after recovery?

2.24 Using Freestanding Facilities

Many VISTA health benefits plans have less member responsibility when outpatient surgery and diagnostic tests, such as lab tests, X-rays, and CT scans are performed in a freestanding facility. When you are referred for one of these outpatient services, ask the physician if the procedure can be done in a freestanding facility. These facilities are listed in your Provider Directory under “Outpatient Care and Services” and can also be found on VISTA’s web site. Refer to your plan documents for your member responsibility.

2.25 Your Payment Responsibilities

Members have certain payment responsibilities as detailed in your plan documents. Please refer to these documents for specific information.

All health benefit plans include a copayment, which is a specific dollar amount, except as otherwise provided for by statute, the member must pay upon receipt of covered services. The most common copayment amounts are listed on your ID card.

Some health benefits plans also have a deductible which is the amount a member must pay before VISTA will make any payment toward covered services.

Some health benefits plans also have coinsurance which is the sharing of expenses for covered services between VISTA and the member. Coinsurance is expressed in a percentage rather than a dollar amount.

Some health benefits plans may include an annual maximum benefit, which means that VISTA will pay up to the annual maximum per calendar year. The costs for any services received above the maximum benefit are your responsibility.

All health benefits plans include a lifetime maximum benefit, which means that VISTA will pay benefits up to the lifetime maximum set forth in your plan document. Once a member reaches the lifetime maximum benefit, coverage for the member ends.

You are always responsible for payment for services that are not covered by your health benefits plan.

If your health benefits plan is subject to a deductible or coinsurance provision, or if VISTA denies payment because the services are not covered by your plan, you will receive an Explanation of Benefits (“EOB”) from VISTA which explains how each claim was paid by VISTA, VISTA’s responsibility for payment and your responsibility for payment.

2.26 Filing Claims for Payment

Whenever you see a participating provider for covered services, the provider will send a claim to VISTA. You are only responsible for your copayment, deductible or any coinsurance required by your benefits plan. You do not have to file a claim for payment. If you see a non-participating provider, the provider may submit the claim for you, or may require that you pay the bill. If you pay the bill, you may submit a request to VISTA for reimbursement as explained in section “Requesting Reimbursement.”

2.27 Requesting Reimbursement

If you see a provider for an emergency medical condition while inside or outside the service area or you do not have your ID card with you when you fill a prescription at a participating or nonparticipating pharmacy, you may be required to pay for services. When this occurs, you may send a request for reimbursement to VISTA. You may obtain a Reimbursement Form by using the IVR system or calling Customer Service.

To request reimbursement, you must:

1. Ask the provider for an itemized bill at the time you receive the service. “Itemized” means that the bill includes:

• Date of service
• Procedure code
• Diagnosis code
• Provider’s UPIN/NPI number
• The amount charged
• The amount you paid

If you receive services in a foreign country, the bill must be in English and the amounts charged and paid must be in U.S. currency with the exchange rate attached for validation. It is your responsibility for obtaining the necessary documents and translations.

2. Submit the original itemized bill with a completed Reimbursement Form, along with proof of payment, to VISTA. Keep a copy for your records. The mailing address is located on the back of your ID card and on the reimbursement form.

2.28 If you receive a Bill from a Provider

Florida Law specifies that, except for copayments, deductibles or coinsurance, HMO members cannot be responsible for any bills from participating providers for covered services. Therefore, you should not receive a bill for covered services except for any copayments, deductibles, or coinsurance that you are responsible for as described in your plan documents or for non-covered services. If you do receive a bill, please contact Customer Service.

NOTE: POS, Open Access Plus, Focused Deductible POS, Focused Deductible Open Access Plus, Focused Deductible Coinsurance POS, Focused Deductible Coinsurance Open Access Plus and Choice and Value Open Access POS members may receive a bill for covered services performed by non-participating providers that may be higher than the allowed amount. In addition to a member’s deductible and coinsurance responsibilities, a member is also responsible for any difference between the allowed amount and amount the provider bills a member for covered services. Any amount a member pays to the provider in excess of the allowed amount will not apply to the member’s deductible or out-of-pocket maximum. When receiving care from participating providers members are not responsible for amounts in excess of the allowed amount.

2.29 Your Prescription Drug Benefit

For complete details regarding your prescription drug benefit please refer to your Prescription Drug Rider.*

The medications that are covered by VISTA are listed in VISTA’s Commercial drug formularies. Only medications approved by the Food and Drug Administration (FDA) are included in VISTA’s drug formularies. VISTA covers these medications only when prescribed for FDA-approved indications, and not when used for investigational or experimental purposes.

You can also view or print a copy of the formulary from VISTA’s web site at www.vistahealthplan.com. Members will be notified of any formulary changes through the Member Newsletter or direct notification.

Your out-of-pocket cost for a prescription drug depends on the designated tier for your medication, such as Tier 1, Tier 2, Tier 3 or Tier 4.*

Mail order is available from the participating mail order pharmacy as explained in your Prescription Drug Rider.

*NOTE: State mandated Standard and Basic HMO health benefits plan members have prescription drug benefits explained in your Schedule of Benefits. Out-of-pocket costs for prescription drugs depend on generic, brand and non-formulary designations, as explained in your plan documents.

2.30 Suggestions? Questions? Need Further Assistance?

There may be times when you have a question about your health benefits plan, want to make a suggestion about how we can serve you better, or need further assistance, with the service you received.

VISTA’s Customer Service department is available to assist you Monday through Friday from 8 a.m. to 6 p.m. To reach Customer Service, call the number on your ID card.

If Customer Service is not able to resolve a problem to your satisfaction, the representative will inform you of your rights to file a grievance and give you instructions about the process. The grievance process is also explained in your Certificate of Coverage.

2.31 Provider Malpractice Information

Florida law requires certain physicians/providers to carry malpractice insurance coverage. As a condition of maintaining their license providers are required to post a notice if they do not carry medical malpractice insurance stating “Your physician has decided not to carry medical malpractice insurance. This notice is provided pursuant to Florida law.”

Your Rights

• You have the right to be treated with courtesy and respect, with appreciation of your individual dignity, and with protection of your need for privacy.
• You have the right to a prompt and reasonable response to questions and requests.
• You have the right to know who is providing medical services and who is responsible for your care.
• You have the right to know what member support services are available, including whether an interpreter is available if you do not speak English.
• You have the right to know what rules and regulations apply to your conduct.
• You have the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
• You have the right to refuse any treatment, except as otherwise provided by law.
• You have the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for your care.
• If you are eligible for Medicare, you have the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
• You have the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
• You have the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
• You have the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment.
• You have the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
• You have the right to know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research.
• You have the right to express grievances regarding any violation of your rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served you and to the appropriate state licensing agency.

Your Responsibilities

• You are responsible for providing to the health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
• You are responsible for reporting unexpected changes in your condition to the health care provider.
• You are responsible for reporting to the health care provider whether you comprehend a contemplated course of action and what is expected of you.
• You are responsible for following the treatment plan recommended by the health care provider.
• You are responsible for keeping appointments and, when you are unable to do so for any reason, for notifying the health care provider or health care facility.
• You are responsible for your actions if you refuse treatment or do not follow the health care provider’s instructions.
• You are responsible for assuring that the financial obligations of your health care are fulfilled as promptly as possible.
• You are responsible for following health care facility rules and regulations affecting your care and conduct.