2014 FC Eng 2 Ded
12
ǁǁǁĨƌĞĞĚŽŵĐĂƌĞďĞŶĞĮƚƐĐŽŵ Enrollment Guide Keeping You Healthy.
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Transcript of 2014 FC Eng 2 Ded
Enrollment Guide
Keeping You Healthy.
for you.
FreedomCare Enrollment Guide Page 1
Welcome to FreedomCare
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FreedomCare Enrollment Guide Page 2
BENEFITS COVERAGE
Once a year
Once a year
women Once a year
Once a year
Once a year
anemia
children
children
BENEFITS COVERAGE
children
in children
olderOnce a year
and older
children
children
BENEFITS COVERAGE
FreedomCare Enrollment Guide Page 3
Your member ID card
Now that you are enrolled in FreedomCare, you will receive your ID card detailed below. Your card
doctor/provider. Make sure to present your
package can bring you to a healthier lifestyle and how you have fully
important things in life.
available for you to purchase.
To locate a participating provider please call 844-657-1575
Discount Prescriptions
Employer NameGroup #: 2014000
Name: John A DoeMember ID#: 2014000XXXXX
RX Bin#: 247007
RX Group#: 2014000 RxBin 610268PCN PHXD
RxGRP FREEDOM
Locate a provider in your network.
Front Back
For Provider Use Only
Provider should verify eligibility before providing treatment.Provider Services: 844-798-4878Mail completed claim forms to
Red Rock Management Services, LLC5130 South Fort Apache #215-365
Las Vegas, NV 89148
Member Services: 844-657-1575Pharmacy Services: 844-657-1575
Call this number to speak with a member
Call this number to speak with a the pharmacy help desk.
FreedomCare Enrollment Guide Page 4
Standard
$10
$5,000
$400
$400
$100
$75
$1,000
$1,000
$100
$10
$7,000
$1,000
$150
$500
$50
$200
$75
$1,000
$1,000
$200
Elite
$10
$9,000
$1,000
$150
$500
$50
$200
$1,000
$3,000
$3,000
$200
FreedomCare Enrollment Guide Page 5
SAMPLELE
00
E$400
$4LEE0E
To learn more about enrolling in the Minimum Value Plan,please call 844-300-6497 (toll free)
You are being offered an Affordable Care Act compliant health plan that is affordable and meets minimum value. This offer of coverage is your opportunity to enroll in an eligible employer sponsored plan, or to decline coverage.
Please note that this offer of coverage does not extend to your spouse. This offer of coverage is made to employees and dependents as mandated by the Affordable Care Act.
This offer of coverage was made to you as an adequate notice and representation of the offer of coverage.
You have fifteen (15) days to enroll in this eligible employer sponsored plan which is a reasonable period of time in which to accept to enroll or to decline coverage. There are NO conditions on this offer of coverage.
Affordability NoticeOur Minimum Value Plan is affordable under the Affordable Care Act with the employee portion of the premium totaling 9.5% of a monthly amount determined as the federal poverty line for a single individual for the applicable calendar year, divided by 12. This amount increases each year according to the federal poverty scale. Since this amount will vary based on rate of pay, please call the enrollment center listed below to learn more.
Minimum Value Plan
FreedomCare Enrollment Guide Page 6
Deductible Coinsurance Out of PocketNetwork Non-Network Network Non-Network Network Non-Network$6,350 Not Covered 100% 0% $6,350 Not Covered$6,350 Not Covered 100% 0% $6,350 Not Covered
MAJOR MEDICAL BENEFITS Network Non-NetworkNot Covered
PCP, Urgent Car stNot Covered
Not Covered
Rx Coverage(Generic & Preferred Br
$6,350 Not Covered
Not CoveredMent avior stance Not Covered
Imaging (CT/PET Sc Not CoveredNot Covered
-
P sic rap
Not Covered
ServicesNot Covered
Not Coveredrsing F Not Covered
(e. ator rger ntNot Covered
ServicesNot Covered
ted ted
FreedomCare Enrollment Guide Page 7
Medical
Member Services at 844-657-1575.
call 844-657-1575.
Member Services
Member Services at 844-657-1575.
call 844-657-1575.
Dental
Page 8
FreedomCare Enrollment Guide Page 9
To locate a participating provider please call 844-657-1575
Discount Prescriptions
Employer NameGroup #: 2014000
Name: John A DoeMember ID#: 2014000XXXXX
RX Bin#: 247007
RX Group#: 2014000 RxBin 610268PCN PHXD
RxGRP FREEDOM
MDLIVE Family Account
FreedomCare Enrollment Guide Page 10
• Acne• Asthma• Cold & Flu• Diarrhea• Fever• Insect Bites• Nausea• Sinus Infection• UTI
by MDLIVE:• Allergies• Bronchitis• Constipation• Ear Infection• Headache• Joint Aches• Rashes• Sore Throat• and more!
