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									                                                                                        Effective January 1, 2007



Quick Reference Guide
MVP Health Care is proud to introduce MVP Gold, a new Medicare Advantage HMO plan. MVP Gold is designed
specifically for people who qualify for Medicare due to age or disability. MVP Gold is available with and without
prescription drug coverage and includes all Medicare covered services. Our goal is to provide Medicare-eligible
individuals with a choice of affordable health care options in the communities MVP serves.

This Quick Reference Guide provides information               Providers and their office staff can contact the
on MVP Gold plan types, member ID cards,                      MVP Gold Pharmacy department via:
pre-authorization requirements, behavioral health             • Telephone: 1-800-568-0458
services, pharmacy services and online resources.             • Fax: 1-800-401-0915
MVP Gold Service Area                                         Behavioral Health
Effective January 1, 2007, MVP Gold will be                   Behavioral Health Services for MVP Gold will
offered to Medicare-eligible individuals and through          follow MVP’s existing HMO process. MVP does
employer groups in Albany, Dutchess, Montgomery,              not require a referral from a PCP for behavioral
Onondaga, Rensselaer, Saratoga, Schenectady and               health services when a participating MVP Gold
Ulster counties. It will also be offered exclusively to       provider renders care. However, there is a notifica-
employer groups in Broome and Cayuga counties.                tion requirement — either the provider or member
                                                              must call the MVP Behavioral Health Access
Claims Submission, Correspondence
                                                              Center at 1-800-893-2905 to register care prior
and Appeals
                                                              to treatment.
Electronic claims can be submitted via the MVP
Web site or standard MVP EDI format. Paper claims,            Please note:
correspondence and appeals should be mailed to:               • Up to 10 initial outpatient visits may be
  MVP Gold                                                      authorized for mental health
  PO Box 2207
  Schenectady, NY 12301                                       • Up to 20 initial outpatient visits may be
                                                                authorized for substance abuse
Pharmacy Services                                             • Please fax MVP outpatient treatment reports
The MVP Gold plan options will be offered with and              (OTRs) to 1-800-398-2576
without prescription drug coverage. MVP offers a
plan with drug coverage under Medicare Part D.                • OTRs are available on the MVP Web site at
A printed copy of the MVP Gold Formulary was                    www.mvphealthcare.com.
mailed to all MVP Gold participating providers.
The MVP Gold Formulary is also available via the
MVP Web site (www.mvphealthcare.com) and
ePOCRATeS .   ®



                                                                                                                     TR
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                                             Services Rendered                                                    MVP Gold Employer Group
Primary Care Physician Office Visit                                                                              $15 copay/Office Visit
   X-Rays and Other Imaging                                                                                      $20 copay/Office Visit
   Physical Exams                                                                                                $15 copay/Office Visit
   Diagnostic Tests and Lab                                                                                      $0 copay/Office Visit
   Professionally Administered Rx                                                                                $20 copay/Office Visit
Specialist Office Visit                          (Excluding Psychiatric Services)                                $20 copay/Office Visit
   X-Rays and Other Imaging                                                                                      $20 copay/Office Visit
   Outpatient Services/Surgery                                                                                   $0 copay/Office Visit
   Diagnostic Tests and Lab                                                                                      $0 copay/Office Visit
   Professionally Administered Rx                                                                                $20 copay/Office Visit
Hospital Services                                Hospital Inpatient                                              $100 per stay/$300 max per year ($0 w/rider)
                                                 X-Rays and Other Imaging                                        $20 copay/Office Visit
                                                 Emergency Care                                                  $50 copay/Office Visit
                                                 Ambulance Services                                              $50 copay/Office Visit
                                                 Skilled Nursing Facility – 3-day prior hospital stay required   $0 (day 1-15) $65 (days 16-100)
Mental Health and Substance Abuse Services       Inpatient Mental Health                                         $100 per stay/$300 max per year ($0 w/rider)
                                                 Outpatient Mental Health                                        $20 1st visit, 50% after
                                                 Mental Health Specialty Services                                $20 1st visit, 50% after
                                                 Outpatient Substance Abuse                                      50% co-insurance
Other Medical Services                           Urgently Needed Care                                            $20 copay/Office Visit
                                                 Cardiac Rehab                                                   $20 copay/Office Visit
                                                 Physical, Speech and Occupational Therapy (Outpatient)          $20 copay/Office Visit
                                                 Chiropractic Services                                           $20 copay/Office Visit
                                                 Podiatry Services                                               $20 copay/Office Visit
                                                 Home Health Care                                                $0 days 1-20, $20 days 21+
                                                 Hospice                                                         Medicare-approved Hospice Only
                                                 Durable Medical Equipment (DME)                                 20% coinsurance
                                                 Prosthetic Devices                                              20% coinsurance
                                                 Diabetes Supplies                                               20% coinsurance
                                                 Diabetes Training & Nutritional Therapy                         $20 1st visit, $0 visits 2 & 3
                                                 Renal Dialysis                                                  $0 copay
                                                 Bone Mass Measurement                                           $0 copay
                                                 Colorectal Screening                                            $0 copay
                                                 Immunizations (Hepatitis B, Influenza, and Pneumonia)           $0 copay
                                                 Mammography Screening                                           $0 copay
                                                 Pap Smears                                                      $0 copay
                                                 Pelvic Exams                                                    $0 copay
                                                 Prostate Cancer Screening                                       $0 copay
Pharmacy                                         Tier 1 (Generics)                                               $8            $10           $10
                                                 Tier 2 (Brand Name)                                             $40           $25           $30
                                                 Tier 3 (Specialty and $500+ Rx)                                 25%           $40           $50
                                                 Donut Hole Coverage                                             Rider Available
Hearing Services                                 Hearing Exam                                                    $20 copay/Exam
                                                 Hearing Aids                                                    2 Riders: $600 every 3 years; or 1 per ear/3 years
Vision Services                                  Eye Exams                                                       $15 Routine, $20 Medical
                                                 Post-cataract Surgery                                           20% coinsurance
                                                 Eye Wear                                                        Rider available
Additional Services                              Health Wellness Education                                       $0 copay
                                                 Travel Benefit                                                  30% co-insurance; $3,000/year maximum benefit
                                                 Silver Sneakers                                                 No cost
                                                 Health Dollars                                                  No cost

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MVP Gold Contact Information
Please call the appropriate number listed below for all MVP Gold related questions:
                                                                                                                                                  New York
                                                                                                        Member ID: 81234567800
MVP Gold Provider Claims Services..................................................1-800-671-7527
                                                                                                        JOSEPH SAMPLE
Utilization Management (For pre-authorization and DME).........1-800-568-0458 ..........1-800-280-7346 (fax)
                                                                      Group #: 247799
                                                                                                        Effective Date: 01/01/2007
Referrals ........................................................................................................1-800-568-0458...........1-888-819-2103 (fax)
                                                                                      Plan Type:
Behavioral Health ......................................................................................1-800-893-2905...........1-800-398-2576 (fax)
                                                                                                 MVP Gold
                                                                                                           Member Copayments
Pharmacy......................................................................................................1-800-568-0458...........1-800-401-0915 (fax)
                                                                                                       PCP Office Visit: $10        Specialist Office Visit: $15
                                                                                      Inpatient Hospitalization: $100       Emergency Room: $50
Disease and Case Management..........................................................1-800-893-3913 ............1-800-398-1420 (fax)
                                                                                      H9859
MVP Gold Sales/Marketing..................................................................1-800-671-7504


Sample MVP Gold ID Card
                                                                New York               TO MEMBERS: Your Primary Care Physician (PCP) must provide
                      Member ID: 81234567800
                                                                                       or arrange for all services except emergency or urgently needed
                      JOSEPH SAMPLE                                                    care, for which you may go to the nearest medical facility. Contact
                                                                                       your PCP as soon as possible to coordinate additional care.
                      Group #: 247799
                                                                                       Member Services: 1-800-209-3945 / TTY 1-800-662-1220
                      Effective Date: 01/01/2007                                       Mental Health and Substance Abuse Referrals: 1-800-836-1430

    Plan Type:                                                                         TO PHARMACISTS: Medco Health Code MVPCOMM
    MVP Gold                                                                           TO PROVIDERS: Submit claims to:
                         Member Copayments                                             MVP Health Care PO Box 2207 Schenectady, NY 12301-2207
                                                                                       Travel benefits applies; contact MVP for details.
    PCP Office Visit: $10                 Specialist Office Visit: $15                 For benefits verification, call 1-800-671-7527
    Inpatient Hospitalization: $100       Emergency Room: $50
                                                                                       Your benefits are provided by MVP Health Plan, Inc.
    H9859                                                                              PO Box 2207, Schenectady, NY 12301 www.mvphealthcare.com




Pre-authorization Requirements
Virtually all of the same requirements for our fully-insured HMO/POS lines of business will be in effect
    the MVP Gold plan. The current MVP provide
for TO MEMBERS: Your Primary Care Physician (PCP) mustUM Policy Guide details all pre-authorization and case manage-
    or arrange for all services except emergency or urgently needed
    care, for which you relating to the medical Gold plan.
ment guidelines may go to the nearest MVP facility. Contact All MVP Gold products will use MVP’s existing medical
    your PCP as soon as possible to             additional care.
management policies for coordinate 1-800-662-1220
                                       authorizations. Please note: MVP Gold has a different set of pre-authorization
    Member Services: 1-800-209-3945 / TTY
    Mental the and Substance Abuse Referrals: 1-800-836-1430
rules for Healthpharmacy benefit. Please refer to the MVP Gold Formulary for detailed information.
    TO PHARMACISTS: Medco Health Code MVPCOMM
Referrals
    TO PROVIDERS: Submit claims to:
    MVP Health Care PO Box 2207 Schenectady, NY 12301-2207
Providers can submit referrals online at www.mvphealthcare.com or fax referrals to 1-888-819-2103.
    Travel benefits applies; contact MVP for details.
    For benefits verification, call 1-800-671-7527
Providers can call the UM department at 1-800-568-0458 and choose the MVP Referral Unit option
     Your                       MVP Health Plan, Inc.
on the benefits are provided byNY 12301 MVP Gold products will use MVP’s existing medical management policies
          telephone prompt. All www.mvphealthcare.com
     PO Box 2207, Schenectady,
for referrals. Please refer MVP Gold members to participating MVP Gold providers and facilities only.
The MVP Participating Provider Directory lists all MVP Gold providers in red font. For the most up-to-date
listing, refer to our online participating provider directory (www.mvphealthcare.com).




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Disease/Case Management                                 Online Resources
MVP Gold members have access to the following           Detailed information about the MVP Gold
Disease and Case Management programs:                   plan is posted on the MVP Web site
 • Acute Care Management                                (www.mvphealthcare.com). Using the MVP
 • Care of the HeartSM (Heart Failure)                  Web site, providers and their staff can verify
                                                        member eligibility, submit claims and check
 • Breathe BetterSM (COPD/Asthma)
                                                        claims status, submit referrals and review
 • Take Control of DiabetesSM
                                                        referral status, access the MVP Gold Formulary,
 • CareSupportSM (Cancer)                               e-mail Professional Relations and read the
 • Behavioral Health.                                   Healthy Practices newsletter. You also have
A team of experienced, professional registered          access to MVP news, updated information,
nurses and social workers are available to assist       forms and can review MVP’s new Practitioner
MVP Gold members with:                                  Resource Manual and Physician Quality
  • Coordination of medical services and link           Improvement Manual and Tool Kit.
    to community resources
                                                        Non-Covered Services
  • Education to improve self care abilities and        The following services are not a covered benefit:
    disease knowledge
                                                         • Dental Services
  • Opportunities to reinforce medication manage-
                                                         • Transportation Services
    ment and early symptom identification to
    reinforce your plan of care.                         • Hospice Services (original Medicare covers
                                                           hospice care in a Medicare-certified hospice).
For additional information, call the MVP Gold
Service Center at 1-800-671-7527 from 8:00 a.m.
to 5:00 p.m.




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