This section includes "Frequently Asked Questions" for Prospective members, Current members, Brokers, and Providers. Please use the drop-down box menus below to select your group type, then click GO. The appropriate information will appear below on this page as a list of clickable links. You can also contact us toll-free by phone or email us for more information.

This section includes "Frequently Asked Questions" for Prospective members and Current members. Please use the drop-down box menus below to select your group type, then click GO. The appropriate information will appear below on this page as a list of clickable links. You can also contact us toll-free by phone or email us for more information.

This page provides more information about our prescription drug coverage and formularies (lists of drugs that are covered by your plan). If you have other questions you are welcome to contact us by phone or send us an email.

Northeast Community Care covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

This section includes "Frequently Asked Questions" for Brokers. The appropriate information is listed below on this page as a list of clickable links. You can also contact us toll-free by phone or email us for more information.

Northeast Community Care is a Medicare Advantage health plan offered by Arcadian Health Plan, Inc.. In order to offer a Medicare Advantage health plan, we have a Medicare Advantage contract with the Center for Medicare and Medicaid Services, or CMS.

Please click one of the following links to learn more about working with us and the benefits of our plans. You can also contact us or send us an email with any questions.

The Providers home page provides complete information about Eligibility verification and procedures, Claims, Referrals, and Authorizations.

General Information

• Where can I find plan benefit information?
• Where can I find the Formulary or drugs covered, and where do I go to get my prescription drugs?
• Where can I search for a Provider?
• How do I go about seeing my Specialist?
• Where can I search for a Dentist or find Dental Benefits information?
• Where can I find more information about Routine Vision coverage?
• What do I present as coverage when I am seeking medical and prescription services?
• What coverage do I have out of my service area?
• How do I go about obtaining Durable Medical Equipment (DME) supplies?

Select the name of your plan in the left-hand column to view the plan description page. On that page you will find links to open the official Summary of Benefits and Evidence of Coverage plan documents, in addition to all your other benefits.

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Select the name of your plan in the left-hand column to view the plan description page. On that page you will find links to open the official Formulary and Notice of Negative Formulary Changes plan documents.

You can get your prescription drugs by mail order, or by visiting a local network pharmacy.

Prescriptions by Mail Order

You can send for your medications by mail via Caremark Mail Order Pharmacy. For more information about how to utilize the Mail Order Pharmacy, please contact Member Services.

You can use our network mail order pharmacy service to fill prescriptions for what we call "maintenance drugs." These are drugs that you take on a regular basis, for a chronic or long-term medical conditions. These are the only drugs available through our mail order service. When you order prescription drugs through our network mail order pharmacy service, you must order 90-day supply of the drug. Generally, it takes us 14 days to process your order and ship it to you. However, sometimes your mail order may be delayed. If your prescription is delayed, contact your doctor to obtain a prescription for immediate use. Have the short-term prescription filled at a retail pharmacy in the network. You are not required to use our mail order services to get an extended supply of maintenance medications. You can also get an extended supply through some retail network pharmacies.

Visit a Local Network Pharmacy

To search for a local network Pharmacy, use the link in the "Help me Find a..." section in the left-hand column. That link will open another browser window or tab for a search with our Pharmacy provider.

For more information, please see the Prescription Drug and Formulary Frequently Asked Questions page.

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To search for a local Provider online, use the Doctor link in the "Help me Find a..." section in the left-hand column. You can also visit the Liberty Dental Plan website.

Select the name of your plan in the left-hand column to view the plan description page. On that page you will find links to open the complete Provider Directory or Dental Directory plan documents, in addition to all your plan benefits information.

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It is important that you schedule an appointment with your Primary Care Physician so that he or she can direct your medical care. Your primary care physician will coordinate the care you receive and is responsible for facilitating the referral process when you need to see specialists.

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Your oral health is important and critical to your overall health. To keep your teeth and gums healthy, we encourage you to use your Liberty Dental plan benefits to improve and maintain your oral health. Preventive Dental benefits are not available for the Plus Plan (HMO) plan.

Search for a local Dentist online

Click the Dentist link in the "Help me Find a..." section in the left-hand column. That link will open another browser window or tab for your search with our official Dental network provider. You can also visit the Liberty Dental Plan website.

Access information about your Dental Coverage

Select the name of your plan in the left-hand column to view the plan description page. On that page you will find links to open the Complete Provider Directory or Dental Directory plan documents, in addition to all your plan benefits information.

Preventive Dental benefits may not be available in all service areas. Please review the Summary of Benefits to see if your plan has Preventive Dental coverage.

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To keep your eyes healthy and your vision clear, use your VSP (Vision Service Plan) benefits that are covered with your Northeast Community Care plan.

Search for a local Optometrist or Vision Service Provider online

Click the Vision Services Provider link in the "Help me Find a..." section in the left-hand column.

Access information about your Routine Vision Coverage

Select the name of your plan in the left-hand column to view the plan description page. On that page you will find links to open all your plan benefits information documents containing details about your covered eye exams and eyewear coverage. Open the Provider directory to view a printable list of Optometrists in your area.

Routine Vision benefits may not be available in all service areas. Please review the Summary of Benefits to see if your plan has Routine Vision coverage.

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You should always carry your Northeast Community Care ID card and state Medicaid card or letter, if applicable, to present as coverage. Contact us or email us if you need to order a new ID card.

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You are covered for emergency and urgent care both in and out of the country worldwide. To view more details, please open and review the Evidence of Coverage document for your plan. This is located on your plan description page — select your plan name in the left-hand column for more information.

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Your Primary Care Physician (PCP) needs to submit an authorization for those supplies and you will be directed to a DME provider. An approved authorization will allow each member to utilize their Durable Medical Equipment supplies.

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General Information

• What is a Formulary?
• What are drug tiers?
• Can the formulary change?
• What if my prescription drug is not on the list in the Formulary?
• How do I fill a prescription through the network mail order pharmacy service?
• What is a network pharmacy?
• How do I fill a prescription outside the network?
• How do I submit a paper claim?
• What is a specialty pharmacy?
• What is an Exception?
• How can I request an Exception or Coverage Determination?
• How long will it take for a decision?
• What is the Coverage Gap or "Doughnut Hole"?
• Will everyone fall into the Coverage Gap?
• Can I delay reaching the coverage gap?
• How will I know where I am in relation to the Coverage Gap?

A formulary is a list of drugs selected by Northeast Community Care in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Northeast Community Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Northeast Community Care network pharmacy, and other plan rules are followed.

The formulary may change during the year; this website is updated monthly with the latest formulary lists. Just select your plan name link from the list in the left-hand column for all your benefit documents on one page.

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Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your coinsurance or cost-sharing depends on which tier your drug is in.

If you have a Specialty Drug in a tier that is not covered by our regular formulary, you may contact a specialty pharmacy. Please see the What is a Specialty Pharmacy link on this page for more information.

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Yes, we may remove drugs from our formulary, move a drug into a different cost-sharing tier, add prior authorization, and change quantity limits and/or step therapy restrictions. We must notify affected members at least 60 days before the change becomes effective, unless the drug is removed from the market by the manufacturer or deemed unsafe by the Food and Drug Administration-in which case the drug will be removed from our formulary immediately and affected members will be notified.

Formularies are updated monthly on this website. If you have an additional question or about your formulary, please contact Member Services by phone or send us an email.

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Please contact your prescribing physician so that he or she may submit a prior authorization request. This is also called an "exception". For more information, see the What is an Exception section on this page.

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You can use our network mail order pharmacy service to fill prescriptions for drugs that you take on a regular basis for chronic or long-term medical conditions. It generally takes us 14 days to process your order and ship it to you, but always order your mail order prescriptions at least 2 weeks prior to your need. If your prescription is delayed, you can contact your doctor to have a short-term prescription filled for immediate use. You are not required to use our mail order services to get an extended supply of maintenance medications. You can also get an extended supply through some retail network pharmacies.

Note: You can also fill prescriptions through a local network Pharmacy — to find a location near you, use the link in the "Help me Find a..." section in the left-hand column. That link will open another browser window or tab for a search with our Pharmacy provider.

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A network pharmacy has a contract with us to provide your covered prescriptions. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. You may switch between network pharmacies as often as you'd like, but keep in mind that you must either have a new prescription written by a doctor or have the previous pharmacy transfer the existing prescription if any refills remain.

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We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

• If you are unable to get a covered prescription drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

Before you fill your prescription in these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you go to an out-of-network pharmacy for the reasons listed above, you may have to pay the full cost (rather than paying just your co-payment). You can ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay will help you qualify for catastrophic coverage (please refer to the Catastrophic Coverage section under Outpatient Prescription Drugs in the Summary of Benefits). If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you went to a network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

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When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address:

Caremark Claims Department
P.O. Box 52193
Phoenix, Arizona 85072-2193

Click here to open the Caremark Claim Form as a printable pdf (Download Adobe Reader )

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A specialty pharmacy usually fills prescriptions for high-cost oral and self-injectable medications listed on your formulary as a Specialty Drug in a tier. There are two preferred specialty pharmacies that are recommended for your use, Axium Healthcare and Caremark Specialty. To fill a prescription from the pharmacy of your choice, simply complete the corresponding form below and send together with your prescription. For more information, please contact the specialty pharmacy of your choice:

Axium Healthcare: 1-888-315-3395

Caremark Specialty: 1-800-237-2767

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An exception is a type of coverage determination. You may ask us to make an exception to our coverage rules in certain situations.

• You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
• You may ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you may ask us to waive the limit and cover more.
• You may ask us to provide a higher level of coverage for your drug. If your drug is contained in our highest tier subject to the tiering exceptions process, you may ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier subject to the tiering exceptions process instead. This would lower the coinsurance/co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the 4th tier designated as the high-cost/unique drug tier.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan formulary or the drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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Please call Member Services if your doctor has prescribed a medication(s) for you that is not on formulary or if the medication is subject to prior authorization or step therapy. You can also submit your request in writing or by fax.

Contact us for more information.

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A decision can be a "standard coverage determination" (typically within 48-72 hours) or it can be an "expedited coverage determination" (typically within 24 hours). You can ask for an expedited decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.

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Sometimes called the "doughnut hole" or the "gap," the coverage gap is a standard guideline set by Medicare. After the total yearly drug costs paid by you and Northeast Community Care have reached $2,830, you are responsible for paying 100% of your prescription costs until you have paid $4,550 in yearly out-of-pocket costs.

If you have extra coverage from a state program or if you have limited income and qualify for extra help, you will not be affected by the coverage gap.

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No, people who qualify for a low income subsidy and people whose drugs cost no more than $2,830 in the calendar year will not fall into the gap.

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Yes. Using lower cost drugs will make your initial coverage last longer. Ask your doctor if generics or less expensive brand-name drugs would work just as well as the ones you now take. Choosing these drugs could also reduce your co-payments. Take advantage of the generic discount programs offered by some of the chain pharmacies, such as Walmart and Target. Be sure to ask for the special pricing and always use your health plan ID card so that all your prescription records will be available.

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The monthly statement (EOB) you receive from your plan will include this information. If you have any questions on your Explanation of Benefits please contact Member Services. If you see a pharmacy claim that you are not sure is correct, please call us as soon as possible and let us look into the issue for you. We want to make sure all the information on your benefit statement is accurate.

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General Information

• What is the procedure for enrolling new members?
• Where can I search for a local network Provider or Pharmacy?
• How do I access plan benefits information?
• Where can I get marketing materials?
• Where can I go to get certified?

After getting certified with our plan and procuring your Broker Writing number from your local office, you are ready to begin enrolling members.

Enroll Online

Arcadian has a convenient online enrollment system available on this website. Simply click the Enroll Online button at the top of every page to go to the enrollment portal page. As soon as you submit the application on the website it will be sent for review and processing.

Note: In order to open and use the online enrollment application, you must use a recent version of the Microsoft Internet Explorer browser. You can download this software for free on the Microsoft website. You can also enroll members by fax or phone.

Enroll by Fax

Print the enrollment form located on the plan description page. (See the left-hand column for plan choices in this market). Fax it in to the number listed on the contact us page.

Enroll by Phone

Call: 1-866-598-2127 to enroll prospects over the phone. Our operating hours are: Monday through Saturday 9:00 a.m. to 7:00 p.m. EST. Please be sure to review the Summary of Benefits with the prospect prior to placing the call and have their Medicare card, Medicaid card (if applicable). The Member Service operators will be able to answer specific plan questions.

Enroll using a printed application

The best method for submitting a paper application is to fax it into your local or regional office if you cannot personally bring it in on the same day. You can also use an overnight mailing method, but fax is preferred.

Important: An agent must turn in an enrollment application within 24 hours to ensure timely processing. If CMS does not receive the application (contract) within 7 days it may be rejected.

Accessing Enrollment Materials and Enrollment Kits

You may print all plan benefits located on each plan description page (see the left-hand column for plan choices in this market). Contact your local General Agent, Broker Manager or Sales Director to pick up enrollment kits at the local office.

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You can use the links on the left side of this page under "Help me find a..." to search for local providers and other information. A new web browser window or tab will open whenever you click a link that leads away from this website.

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Please use the links on the left side of this page to select a plan that is available in this market. On that plan page, you will be able to view and print all of the materials available, including the Summary of Benefits, Provider Directory, and the Enrollment form. For additional information about our benefits such as the value-added SilverSneakers Fitness Program, please review the Why choose Northeast Community Care page.

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You may order marketing materials online by going to the Direct Print Communications  website. If you have any questions about acquiring access to the website, please contact your local office.

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In order to work with Northeast Community Care you must register with us. You must have an active license in every state in which you plan to enroll members.

You also must certify with us each year. Once you are registered, you will be provided with the link to the online certification site. If you have not completed your annual certification, or if you need to register with Northeast Community Care, please contact the local plan office or the national corporate office for more information. You can also email contracting@arcadianhealth.com.

Please note: When you enter the certification site, you can enter login information from a previous year or, if you are new to our site, you can enter as a new user and put in your writing number. If you do not have a writing number, contact your GA/FMO and enter the certification site with their code. The site will assign you a writing number later. The online certification must be completed in one session and you must use your own email address.

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General Information

• What is the background of Northeast Community Care and how do your Medicare Advantage plans work?
• What are the benefits of working with Northeast Community Care as a health service Provider?
• What identification will members have?
• What are the Benefits like?
• How do we handle co-pays?
• How do Referrals and Authorizations work?
• Where do we send claims?
• Who can the member contact if they have a problem?
• How do I become an in-network Provider?

Northeast Community Care is a "Medicare Advantage" plan, previously known as "Medicare +Choice" plans. Medicare Advantage plans provide the same services as Original Medicare with additional coverage. Eligible individuals are free to join our plan during the Open Enrollment period.

Northeast Community Care has formed a network of doctors, specialists and hospitals to provide care for our members. Providers and members will work directly with us on coverage and claims questions. CMS is responsible for oversight. Benefits are offered to Medicare-eligibles who live in Northeast Community Care service area.

The plan is marketed by licensed certified representatives, generally in a group presentation setting but individually if appropriate. Medicare-eligibles must enroll and be confirmed by Medicare before they can become members.

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We believe that our plan will be beneficial to you as a physician practice for the following reasons:

1. Referrals to Specialists from Primary Care Physicians automatically include 2 pre-approved follow-up visits for the Specialist office with no authorization requirements.
2. An available paperless interface through which you will be able to verify eligibility, submit and lookup claims – all through easy to use web-based tools. No more telephone and paperwork hassles!
3. Your existing Medicare patients will have a valuable option with lower out-of-pocket expenses and benefits that include preventive services, pharmacy, vision and hearing.
4. A local office and staff that will be working with you. We are committed to the local market and other underserved areas that do not have sufficient Medicare health plan options available.
5. You will be working with a health plan that offers only Medicare Advantage products. We have a pure focus on Medicare beneficiaries.

Please contact Provider Relations at 1-800-573-8597 or email us for more information or to register with us.

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Each member will have a Northeast Community Care identification card with a unique member ID number. To check Eligibility, contact Member Services.

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Most plans have no deductibles and all services are either paid in full or have a co-pay or co-insurance amount. Primary care office visits are subject to an office co-pay and specialist visits have a low co-pay. Unlike traditional Medicare, the plan has coverage for preventive care services. Our members also have co-pays for other Medicare-covered services such as in-patient hospital care and emergency room visits.

To view the full Summary of Benefits or other plan documents, select a Plan from the list in the left-hand column. The plan description page provides all information for that plan including Provider Directories and links to online search tools.

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You can collect co-pays at the time of service just like any commercial plan or you can wait until the claim is paid and then bill the member for their co-pay.

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Primary Care Physician (PCP) services performed in the office, Well-woman exams and routine gynecologic services from a contracted provider, Annual Bone Densitometry, Diabetic test supplies, most Pulmonary Function tests, Endoscopies (43234-43259), Allergen Immunotherapy (95115-95180), Allergy Testing (95004-95075), lab and simple radiology procedures (including CT scans, EKG's, mammograms and ultrasounds) do not require authorization. PCP's need to submit notification requests for contracted specialty consults. These notifications are automatically approved for the consult and four follow-up visits. All other services require prior authorization and can be requested by the ordering physician (e.g.: PCP or specialist). All services performed by non-contracted providers require authorization.

Notification and authorizations, as well as eligibility verification, are handled most efficiently through "AOS," the Arcadian on-line system. Referrals can also be communicated on a fax form. Please contact Provider Relations for assistance.

The Providers home page provides complete information about Referrals and Authorizations.

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It is our preference to receive claims electronically - Our payor ID is 77045. We have relationships with the following clearinghouses: WebMD, Proxymed, Office Ally and the SSI Group. To check claims status using our automated system call: 1-800-775-6490. Our claims address is:

Claims Department
P.O. Box 4946
Covina, CA 91723

The Providers home page provides quick access to our commonly-used forms as well as information about Eligibility verification and procedures, Claims, Referrals, and Authorizations.

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Members have toll free access to Member Services Toll-free: 1-800-573-8597, TTY/TDD: 1-866-573-8591, 7 days a week, 8 a.m. to 8 p.m. They can also email us to contact a local office representative.

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Providers wishing to participate in our network need to speak with a Provider Relations representative by calling 1-800-573-8597. You can also email Provider Relations for more information or contact us at your local office.

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