vitality for 2019 life. enrollment book · 2019 your health plan for life vitality vitality for...
TRANSCRIPT
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2019
Y
our H
ealth Plan Fo
r LifeV
itality
Vitalityfor Life.
2019 ENROLLMENT BOOK
Medicare Advantage HMOwith Prescription Drugs
San Joaquin CountySanta Clara County
H1426_19_077_MK_ENG_M Approved
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Dear Prospective Member,
Thank you for your interest in Vitality Health Plan of California. TTTaking care of your healthcare needs is something we take very seriously. Because we solely offer Medicare Advantage HMO plans, you have our undivided attention on all matters related to the delivery and payment of your health care. Our focus on Medicare Advantage enables us WR�GHGLFDWH�RXU�WLPH�WR�ĺQGLQJ�LQQRYDWLYH�VROXWLRQV�WR�HYHU\GD\�VLWXDWLRQV�\RX�DQG�\RXU�healthcare providers face.
Vitality Health Plan of California has been approved by Medicare to offer you affordable FRYHUDJH�WKDW��DOORZV�\RX�WR�EHQHĺW�IURP�RXU�KHDOWK�SODQ�HYHQ�ZKHQ�\RXpUH�QRW�VLFN���$V�D� PHPEHU RI 9LWDOLW\ +HDOWK3ODQRI &DOLIRUQLD� \RXZLOO EHQHĺW IURPRXU RIIHULQJ RI PDQGDWRU\� VXSSOHPHQWDO EHQHĺWV WKDW DGGV WR \RXU YLWDOLW\ DQG ZHOO�EHLQJ�� )RU H[DPSOH� ZH DUH� SOHDVHG�WR�RIIHU�\RX�D�VXSSOHPHQWDO�YLVLRQ�EHQHILW�WKDW�FRYHUV�IUDPHV�DQG�OHQVHV�DW�1R &RVW� LQFOXGLQJ )5(( XSJUDGHV WR �¾ÅÊÅƖ¹¾ÈÅÿ¹� 89 &RDWLQJ� 3RO\FDUERQDWH�6FUDWFK�5HVLVWDQW�DQG�$QWL�5HIOHFWLYH�OHQVHV���,�LQYLWH�\RX�WR�OHDUQ�PRUH�DERXW�WKLV�YLVLRQ EHQHILW� LQVLGH� WKLV� ERRN�� � ,I� \RX� DUH� LQWHUHVWHG� LQ� RXU� DQQXDO� ILWQHVV� EHQHILW�� \RX� DUH� ZHOFRPH� WR� XVH� DQ\� ILWQHVV� FHQWHU� ZLWKLQ� RXU� SDUWLFLSDWLQJ� QHWZRUN�� DQ\� GD\� RI� WKH� PRQWK��7KH�FKRLFH�is yours. We are also pleased to offer you a quarterly allowance to spend on more than ����LWHPV�LQ�RXU�2YHU�WKH�&RXQWHU�FDWDORJ�WKDW�PD\�KHOS�\RX�ZLWK� SDLQ�UHOLHI��VOHHS��IOX and allergies, as well as with daily vitamins to keep your nutrition balanced.
When you enroll in Vitality Health Plan of California, we encourage you to visit your primary care physician to complete your annual health risk assessment. That way, \RX DQG�\RXU GRFWRU FDQ�GLVFXVV WKH EHVW FRXUVH RI WUHDWPHQW IRU \RX�� 'XULQJ�WKH IOX VHDVRQ��ZH�HQFRXUDJH�\RX�WR�JHW�\RXU�DQQXDO�IOX�VKRW���:H�NQRZ�WKDW�LWpV�QRW�DOZD\V HDV\� WR JHW� D� VDPH�GD\ DSSRLQWPHQW ZLWK� \RXU SK\VLFLDQ� ZKLFK LV ZK\ ZH KDYH� DUUDQJHG�IRU RXU PHPEHUV WR KDYH WKH RSWLRQ WR UHFHLYH WKHLU IOX�VKRW DGPLQLVWHUHG DW DQ\ RI RXU�SDUWLFLSDWLQJ�QHWZRUN�SKDUPDFLHV���,WpV�WKDW�HDV\�
As you review the benefits we have to offer, we hope you find that Vitality Health Plan of California meets your healthcare needs. Should that be the case, we look forward to serving you to the best of our ability.
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Vitality Health Plan of California is a Medicare Advantage HMO plan with a0HGLFDUH�FRQWUDFW��(QUROOPHQW�LQ�WKH�3ODQ�GHSHQGV�RQ�FRQWUDFW�UHQHZDO�
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___________________________________________________________
_____________________________________________________________________
2019 SCOPE OF SALES APPOINTMENTCONFIRMATION FORM
The Centers for Medicare and Medicaid Services require agents to document the scope of a marketing appointment prior to any in-person sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential, and should be completed by each person with Medicare or his/her authorized representative.
Please initial below beside the type of product(s) you want the agent to discuss.
Medicare Advantage and Prescription Drug Plan (Part C and D)
Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by aMedicare plan. They do not work directly for the Federal government. This individual may also be paid basedon your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan. Your current or future Medicare enrollment status will not be impacted, and automatic enrollment will not occur.
Beneficiary or Authorized Representative Signature and Signature Date:
Signature: _____________________________________ Signature Date: ______________________________
If you are the authorized representative, please sign above and print below:
Representative’s Name
Your Relationship to the Beneficiary
Agent Name: Agent Phone:
Beneficiary Name: Beneficiary Phone (Optional):
Beneficiary Address (Optional):
Agent’s Signature: Date Appointment Completed:
Vitality Health Plan of California is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1866-333-3530 (TTY: 711).ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1866-333-3530 (TTY: 711). 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣 1-866-333-3530㸦TTY㸸711㸧ࠋ
H1426_19_075_MK_ENG_C Approved
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• Vision Beneðt Summary
TABLE OF CONTENTS
IMPORTANT INFORMATION COVERED IN THIS BOOK
•
Welcome Letter
• Scope of Sales Appointment &onðrmation )orm
• Service Area Map
• Benefit Highlights Book -some of the benefits you willreceive as a Vitality member
• Over-the-Counter �O7C� Beneðts
• Vitality Choice (HMO) 'ental Beneðts
• Vitality Plus (HMO) 'ental Beneðts
• Fitness Program
• Transportation Information
• Medicare Advantage Enrollment Periods -H[SODQDWLRQ�RI�WKH�GLIIHUHQW WLPHV�RI�\HDU�ZKHQ�\RX�FDQHQUROO�RU�PDNH�FKDQJHV WR�\RXU�SODQ
•
Enrollment Form
• Dental Provider Selection Form
• Pre-Enrollment Checklist
• LIS Premium Summary
• Summary of Beneðts
• Language Assistance -if you require enrollmentin another language, please followthe instructions provided
• Non-Discrimination Notice
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Vitality Health Plan of California is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.
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Vitalityfor Life.
2019 BENEFIT HIGHLIGHTS
Medicare Advantage HMOwith Prescription Drugs
San Joaquin CountySanta Clara County
H1426_19_079_MK_ENG_M Approved
-
t
fi se tn he ig e 2
9 B l gh a
1 igp
0 H2V
italit
y C
hoic
e (H
MO
)V
italit
y C
hoic
e (H
MO
) V
italit
y P
lus
(HM
O)
Ser
vice
Are
a M
ust
res
ide
in
S
an J
oaq
uin
Co
unt
y M
ust
res
ide
in
San
ta C
lara
Co
unt
y
Mu
st r
esid
e
in
San
Jo
aqui
n C
ou
nty
or
San
ta C
lara
Co
unt
y
Oth
er E
ligib
ility
Req
uire
men
ts
Mus
t ha
ve M
edic
are
Par
t A
and
Par
t B
M
ust
have
Med
icar
eP
art
A a
nd P
art
B
Mus
t ha
ve M
edic
are
Par
t A
and
Par
t B
Max
imum
O
ut o
f P
ock
et$3
,200
$3,2
00
$6,7
00
For
som
e p
eop
le t
his
may
b
e p
aid
in p
art
or
in f
ull b
y M
edic
aid
or
a th
ird
par
ty
Par
t C
Mo
nthl
yP
rem
ium
$0
$0$0
Par
t D
Mo
nthl
yP
rem
ium
$0
$0
$34.
80*
For
som
e p
eop
le t
his
may
b
e p
aid
in p
art
or
in f
ull b
y M
edic
aid
or
a th
ird
par
ty
*Par
t D
Mon
thly
Pre
miu
m m
ay v
ary
bas
ed o
n th
e le
vel o
f Ext
ra H
elp
you
rec
eive
-
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Hig
hlig
hts
pag
e 3
Vit
alit
y C
hoic
e (H
MO
) S
an
Joaq
uin
Cou
nty
V
italit
y C
hoic
e (H
MO
) S
anta
Cla
ra C
ou
nty
Vit
alit
y P
lus
(HM
O)
San
Joaq
uin
Cou
nt
y &
Santa
Cla
ra C
ounty
Nur
se A
dvi
ceH
otl
ine
$0$0
$0
Pri
mar
y C
are
.EkBD�5HRHS
$0
$0$0
Sp
ecia
list
.EkBD�5HRHS
$0$0
$0
Reh
abili
tati
on
Se r
vice
s (P
hysi
cal,
Sp
ee
ch,
Occ
up
atio
nal T
hera
py)
$0$0
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Lab
Wo
rk$0
$0$0
-
SDk s
M
���!D
�� Hig
hlig
htp
age
4
M
O) y
Hhoic
e (
y C
lita n
Joaq
uin
Cou
nt
ait SV
MO
)y
Hhoic
e (
y C
lita C
lara
Cou
nt
tna ait SV
(H
MO
) y y
lus
Pytilta
Vi n
Joaq
uin
Cou
nt
a C
ount
a C
lar
nt
aa
S & S
Dia
bet
esS
up
plie
s $0
$0
$0
X-R
ays
$0
$0
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
coin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Co
mp
lex
Dia
gno
stic
s (M
RI,
CT-
Sca
n)
$50
$0
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
coin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Ho
me
Hea
lth
Car
e
$0
$0$0
Urg
ent
Car
e5HRHS
$15
$0
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
-
SDk s
M
���!D
�� Hig
hlig
htp
age
5
MO
) y H
hoic
e (
y C
lita n
Joaq
uin
Cou
nt
ait SVM
O)
y H
hoic
e (
y C
lita C
lara
Cou
nt
tna ait SV
y
(H
MO
) y
lus
Pytilta
Vi n
Joaq
uin
Cou
nt
a C
ount
a C
lar
nt
aa
S & S
Am
bul
ance
Ser
vice
s
$100
(W
aive
d if
ad
mit
ted
wit
hin
24 h
our
s)
$1
00
(Wai
ved
if a
dm
itte
dw
ithi
n 24
ho
urs)
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Em
erg
ency
1NNL�5HRHS
$7
5 (W
aive
d if
ad
mit
ted
)w
ithi
n 24
ho
urs
$9
0 (W
aive
d if
ad
mit
ted
)w
ithi
n 24
ho
urs
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
l b
y M
edic
aid
or
a th
ird
par
ty
Inp
atie
nt
Ho
spit
aliz
atio
n (A
cute
Car
e)
$0 p
er d
ay, d
ays
1–90
,($
0 un
limit
ed
add
itio
nal d
ays)
$0
per
day
, day
s 1–
90,
($0
unlim
ited
ad
dit
iona
l day
s)
$1
,340
ded
uct
ible
* d
ays
1–60
; $3
35 p
er d
ay, d
ays
61–9
0;*
$670
per
day
, day
s 90
–120
*
Ski
lled
N
ursi
ng F
acili
ty
(no
pri
or
hosp
ital
stay
req
uire
d)
$0 p
er d
ay, d
ays
1–20
; $5
0 p
er d
ay, d
ays
21–7
5;
$75
per
day
, day
s 76
–100
$0 p
er d
ay, d
ays
1–20
; $5
0 p
er d
ay, d
ays
21–7
5;
$75
per
day
, day
s 76
–100
$0 p
er d
ay, d
ays
1–20
;$1
67.5
0 p
er d
ay,
day
s 21
–100
*
Inp
atie
nt
Men
tal H
ealt
h $1
00 p
er d
ay, d
ays
1–16
,$0
fo
r d
ays
17–9
0
$200
per
day
, day
s 1–
8,$0
fo
r d
ays
9–9
0
$1,3
40 d
edu
ctib
le*
day
s, 1
–60;
$3
35 p
er d
ay, d
ay 6
1–90
;*
$670
per
day
, day
s 90
–120
*
*For
peo
ple
with
full
Med
icai
d, t
his
coin
sura
nce
may
be
pai
d in
par
t or
in fu
ll by
Med
icai
d o
r a
third
par
ty. C
ost
shar
e m
ay c
hang
e in
201
9.
-
�����!DMDkS
Hig
hlig
hts
pag
e 6
V
italit
y C
hoic
e (H
MO
)S
an
Joaq
uin
Cou
nty
V
italit
y C
hoic
e (H
MO
)S
anta
Cla
ra C
ou
nty
V
italit
y P
lus
(HM
O)
San
Joaq
uin
Cou
nt
y &
Santa
Cla
ra C
ounty
Out
pat
ient
M
enta
l Hea
lth
5HRHSR�
$15
$25
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
coin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Out
pat
ient
S
urg
ery
at
Am
bul
ato
ry
Su
rgic
al C
ente
r
$50
$50
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
l b
y M
edic
aid
or
a th
ird
par
ty
Ho
spit
al
Out
pat
ient
S
ervi
ces
&
Dia
gno
stic
s
$75
$75
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
lb
y M
edic
aid
or
a th
ird
par
ty
Dur
able
Med
ical
Eq
uip
men
t
20%
20
%
20%
Fo
r p
eop
le w
ith
f
ull
Med
icai
d, t
his
c
oin
sura
nce
may
be
pai
d in
par
t o
r in
ful
l b
y M
edic
aid
or
a th
ird
par
ty
Ro
utin
e H
eari
ng E
xam
$0
$0
$0
-
SDk s
M
���!D
�� Hig
hlig
htp
age
7
MO
) y H
hoic
e (
y C
lita n
Joaq
uin
Cou
nt
ait SVM
O)
y H
hoic
e (
y C
lita C
lara
Cou
nt
tna ait SV
y
(H
MO
) y
lus
Pytilta
Vi n
Joaq
uin
Cou
nt
a C
ount
a C
lar
nt
aa
S & S
Hea
ring
Aid
Allo
wan
ce
$1,0
00
Lim
it e
very
yea
r $1
,000
Li
mit
eve
ry y
ear
$1,0
00
Lim
it e
very
yea
r
Ro
uti
ne
Acu
pu
nctu
re
NQ�"GHQNOQ@BSNQ�5HRHSR
$0
Up
to
15
annu
alco
mb
ined
vis
its
$0
Up
to
15
annu
al
com
bin
ed v
isit
s
$0
Up
to
15
annu
al
com
bin
ed v
isit
s
Fitn
ess
Mem
ber
ship
wit
hS
ilver
& F
it
$0
A
nnu
al m
emb
ersh
ip
wit
h m
ulti
ple
loca
tio
ns
$0
An
nual
mem
ber
ship
w
ith
mul
tip
le lo
cati
ons
$0
An
nual
mem
ber
ship
w
ith
mul
tip
le lo
cati
ons
Tran
spo
rtat
ion
toP
lan
Ap
pro
ved
P
rovi
der
s
$0
22
one
–way
tri
ps
An
nual
ly
$0
28 o
ne–w
ay t
rip
s A
nnu
ally
$0
Unl
imit
ed o
ne–w
ay t
rip
s A
nnu
ally
An
nual
Max
imum
O
n W
orl
dw
ide
Cov
erag
e
$50,
000
per
yea
r fo
r em
erg
ency
or
urg
entl
y ne
eded
car
e w
hile
o
utsi
de
the
Uni
ted
Sta
tes
$50,
000
per
yea
r fo
r em
erg
ency
or
urg
entl
y ne
eded
car
e w
hile
o
utsi
de
the
Uni
ted
Sta
tes
$50,
000
per
yea
r fo
r em
erg
ency
or
urg
entl
y ne
eded
car
e w
hile
o
utsi
de
the
Uni
ted
Sta
tes
-
Sk s DMD
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hlig
htp
age
8
MO
) y H
hoic
e (
y C
lita n
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uin
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nt
ait SVM
O)
y H
hoic
e (
y C
lita C
lara
Cou
nt
tna ait SV
y
(H
MO
) y
lus
Pytilta
Vi n
Joaq
uin
Cou
nt
a C
ount
a C
lar
nt
aa
S & S
Ro
utin
e
Eye
Exa
m
and
Ref
ract
ion
$0
(1 e
very
yea
r)
$0
(1 e
very
yea
r)
$0
(1 e
very
yea
r)
Eye
wea
r Fr
ames
EQNL�5
2/
Gen
esis
Co
llect
ion
Free
O
nce
ever
y
24 m
ont
hs
Free
O
nce
ever
y
24 m
ont
hs
Free
O
nce
ever
y
24 m
ont
hs
Sin
gle
lens
, Bifo
ca
l, Tr
ifoca
l, Le
ntic
ular
or
S
tan
dar
d P
rog
ress
ive
Len
s
Free
O
nce
ever
y
24 m
ont
hs
Free
O
nce
ever
y
24 m
ont
hs
Free
O
nce
ever
y
24 m
ont
hs
Pho
toch
rom
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-
Proficiency of Language Assistance Services are Available
Hours: 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-333-3530 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-333-3530 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-866-333-3530 (TTY: 711) 。
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-333-3530 (TTY: 711).
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-866-333-3530 (TTY: 711).
주의
: 한국
어를
사용
하시
는 경
우, 언
어 지
원 서
비스
를 무
료로
이용
하실
수 있
습니
다. 1-866-333-3530 (TTY: 711)
번으
로 전
화해
주십
시오
.
ՈՒ
ՇԱ
ԴՐ
ՈՒ
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ապ
ա ձ
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նվճա
ր կա
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են տ
րամա
դրվե
լ լեզ
վակա
ն ա
ջակց
ութ
յան
ծառա
յութ
յուն
ներ:
Զ
անգ
ահա
րեք
1-86
6-33
3-35
30 (T
TY
(հեռ
ատ
իպ)՝
711)
:
وت:هجگا ب رز هنابف سراگ یتفوگیم ک ینت ،دهسلی تابزیناصب ترویار ناگرب یامشف اهارم مب یشاب .د1 ا-866-333-3530 (TTY: 711) متساگب ریدی.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-333-3530 (телетайп: 711).
注意
事項
：日
本語
を話
され
る場
合、無
料の
言語
支援
をご
利用
いた
だけ
ます
。 1-866-333-3530 (TTY: 711)
まで
、お電
話に
てご
連絡
くだ
さい
。
لموحةظإ:ك اذتنتت ثدحكذا لا رغلف ،ة نإمدخ تاملااسةدعلا غليوت ةوترفاكل اب ملناجا.صتب لقر1 م-866-333-3530 (قره مفتالا صو مبلامك: 711).
ੋ
័
ਧਿਆ
ਨ ਦਿ
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ਾਂ ਭਾਸ
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ਸਹਾ
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ਸ ਵ
ਾ ਤ ਹ
ਾਡੇ ਲ
ਈ ਮ
ਫਤ
ਉਪਲਬ
ਧ ਹ
।1-866-333-3530 (TTY: 711) ‘ਤ
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ੋੋ
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ន៖ ប ស
នជា្អ នកន យាយ ភាសា្ខ មែរ, សេវាជ នយ្ផ នែកភាសា ដោយម នគ ត
្ឈ នល គអាចមានរស ាប បរអន្ក។ ចរ ទរស្ព
ទ 1-866-333-3530 (TTY: 711)។
ិិ
ួិិ
ួឺ
ំើ
័
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-866-333-3530 (TTY: 711).
धयान
द :
यदि
आप
हि द
ी बोल
ते ह
ैं तो आ
पके ल
िए म
फत
में भ
ाषा स
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वाए
ं उपल
बध ह
। 1-866-333-3530 (TTY: 711)
पर क
ॉल क
र ।्
ेंं
्े
्ैं
ेंु
เรยน: ถา้คณุพดูภาษาไทยคณุสามารถใชบ้รการชว่ยเหลอทางภาษาไดฟ้ร โ
ทร 1-866-333-3530 (TTY: 711).�
-
Dis
crim
inat
ion
is A
gain
st th
e La
wVitality Health Plan of California complies with applicable Federal civil rights laws and does not discriminate on the basis of race, ethnicity, national
origin, religion, gender, sex, age, mental or physical disability, health status, receipt of health care, claims experience, medical history, genetic
information, evidence of insurability, or geographic location. Vitality Health Plan of California does not exclude people or treat them differently because
of of race, ethnicity, national origin, religion, gender, sex, age, mental or physical disability, health status, receipt of health care, claims experience,
medical history, genetic information, evidence of insurability, or geographic location.
Vitality Health Plan of California:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
ܞQualified sign language interpreters
ܞWritten information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
ܞQualified interpreters
ܞInformation written in other languages
If you need these services, contact Vitality Member Service Department at 1-866-333-3530 (TTY: 711) to help you. Hours are 8 a.m. to 8 p.m.,
seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30. You can also ask for a Civil Rights
Coordinator who works for Vitality Health Plan of California.
If you believe that Vitality Health Plan of California has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file a grievance with:
Vitality Health Plan of California
Member Services Department (Complaints)
18000 Studebaker Road, Suite 960
Cerritos, CA 90703 1-866-333-3530 (TTY: 711) FAX: 1-866-207-6539
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Vitality Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf
-
Vitality Health Plan of California cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad,
edad, discapacidad o sexo.
Vitality Health Plan of California 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。
Vitality Health Plan of California is an HMO with a Medicare contract. Enrollment in Vitality Health Plan of California depends on contract renewal.
T his information is not a complete description of benefits. Call 1-866-333-3530 (TTY 711) for more information 8 a.m. to 8 p.m., seven days a week
from October 1 through March 31, and 8 a.m. to 8 p.m. Monday to Friday from April 1 through September 30.
-
BENEFIT HIGHLIGHTS 2019
Medicare Advantage HMOwith Prescription Drugs
Vitality Health Plan of California 18000 Studebaker Road, Suite 960 Cerritos, CA 90703
For enrollment inquiries, or to speak to a
Member Services representative, please call 1-866-333-3530 or TTY 711
8 a.m. to 8 p.m. seven days a week
from October 1 through March 31, and 8 a.m. to 8 p.m. Monday through Friday from April 1 through September 30
www.VitalityHP.net
www.vitalityhp.net
-
2019 OVER-THE-COUNTER (OTC) PRODUCT CATALOG
Order Online: www.vitalityotc.net
As amember of Vitality Health Planof California��+02�, \ou have an Over-the-Counter (OTC) benefit HYHU\��TXDUWHU�
H1426_19_082_MK_ENG_C $SSURYHG
For more information about your OTC benefit, please see your Evidence of Coverage. Simply order online at www.vitalityotc.net, call Convey customer service at 1-877-906-8273 (TTY: 711), Monday – Friday from 8:00 a.m. to 8:00 p.m., or mail your completed order form, which is located on page 17 of this book. Your order will be shipped directly to your door free of charge.
www.vitalityotc.netwww.vitalityotc.net
-
3
Item # Product Packaging Strength Price
ALLERGY, COLD, FLU, DECONGESTANT & SINUS
1361 All-Nite Cold/Flu 4 oz 12.5 mg, 30 mg, 650 mg $6.50
1360 Cepacol Sore Throat Lozenges 16 ct - $8.00
1008 Chlorpheniramine Maleate Antihistamine 100 ct 4 mg $8.00
1166 Cough & Cold for High Blood Pressure 16 ct - $7.00
1056 Cough Drops, Cherry 30 ct 5.8 mg $3.00
1182 Cough Drops, Sugar Free, Cherry 25 ct 5.8 mg $4.00
1833 Cough Drops, Honey Lemon 30 ct - $3.00
1834 Cough Drops, Menthol 30 ct - $3.00
1054 Cough Syrup, Expectorant 4 oz 200 mg / 10 ml $6.00
1323 Diabetic Tussin DM 4 oz - $9.50
1009 Diphenhydramine Antihistamine 24 ct 25 mg $6.00
1308 Diphenhydramine Antihistamine 100 ct 25 mg $10.00
1180 Guaifenesin Cough Expectorant 60 ct 200 mg $10.00
1806 Irritation Relief Eye Drops 15 ml - $9.50
1178 Mucus Relief DM Expectorant & Cough Suppressant 30 ct 400 mg, 20 mg $10.00
1357 Multi-Symptom Cold Formula 24 ct 10 mg, 5 mg, 325 mg $8.00
1881 Nasacort 60 spray - $24.00
1091 Nasal Decongestant Spray, 12 Hour 1 oz 0.05% $6.00
1931 Nasal Rinse Kit, Saline 1 kit - $18.00
1052 Nasal Spray, Saline 1.5 oz 0.65% $5.50
1792 Personal Steam Inhaler 1 ct - $50.00
1176 Sore Throat Lozenges, Cherry 18 ct - $5.00
1904 Sore Throat Spray, Cherry 6 oz - $7.00
1352 Sudogest PE Nasal & Sinus Decongestant 36 ct 10 mg $7.00
1164 Vapor Rub 3.5 oz 4.7%, 1% $7.00
ANTACIDS & ACID REDUCERS
1313 Alka-Seltzer 36 ct - $11.00
1006 Antacid / Anti-Gas Liquid 12 oz - $7.50
Remember to keep this catalog * ‡ – See Page 16
-
Item # Product Packaging Strength Price
1346 Antacid Chewables 150 ct 500 mg $7.00
1314 Effervescent Pain Reliever 36 ct - $7.00
1108 Famotidine Acid Reducer * 30 ct 10 mg $7.50
1970 Omeprazole Acid Reducer * 42 ct 20 mg $26.00
1900 Ranitidine Acid Reducer 30 ct 75 mg $7.50
1800 Simethicone Anti-Gas Chewables 100 ct 80 mg $8.00
ANTICANDIDAL (YEAST)
1115 Clotrimazole 7-Day Treatment Vaginal Cream (with applicator) 45 gm 1% $10.00
1117 Miconazole 3-Day Treatment Vaginal Cream (with applicator) 1 kit 2% $16.00
1119 Tioconazole 1-Day Treatment Vaginal Cream (with applicator) 1 ct 6.5% $19.00
ANTI-DIARRHEAL, LAXATIVES & DIGESTIVE HEALTH
1316 Beano 30 ct - $9.00
1128 Bisacodyl Enteric Coated Laxative 100 ct 5 mg $6.50
1045 Bismatrol Chewable Tablets 30 ct 262 mg $7.50
1126 Docusate Sodium Stool Softener 100 ct 100 mg $8.00
1733 Enema 4.5 oz - $5.50
1124 Ex-Lax 8 ct 15 mg $8.00
1125 Glycerin Suppository 25 ct 2 gm $7.00
1067 Lactase Capsules 60 ct 9000 FCC units $10.00
1133 Loperamide HCL Anti-Diarrheal * 12 ct 2 mg $6.00
1354 Methylcellulose Fiber Therapy 16 oz - $17.00
1011 Milk of Magnesia 12 oz 400 mg $6.50
1340 Natural Vegetable Laxative 13 oz - $10.00
1317 Pepto-Bismol Cherry 12 oz 525 mg / 30 ml $11.00
1318 Pink Bismuth 8 oz 525 mg / 30 ml $7.00
1012 Polycarbophil Fiber Tablets 90 ct 625 mg $12.00
1130 Senna Plus Stool Softener Plus Laxative 60 ct 8.6 mg, 50 mg $7.00
4 Order Online: www.vitalityotc.net
www.vitalityotc.net
-
Item # Product Packaging Strength Price
ANTI-FUNGAL & ANTI-ITCH
1142 Bactine Solution 4 oz - $10.00
1144 Caldyphen Clear Lotion Local Analgesic 6 oz 1% $8.00
1047 Clotrimazole Antifungal Athlete's Foot Cream 1.5 oz 1% $9.50
1140 Diphenhydramine HCL / Zinc Acetate Anti-Itch Cream 1 oz - $6.00
1074 Hydrocortisone 1% Cream 1 oz 1% $6.00
1874 Medicated Antifungal Foot Powder Spray 4.6 oz - $10.50
1135 Miconazole Nitrate 2% Antifungal Cream 1 oz 2% $9.00
1046 Terbinaȴne HCL Antifungal Cream .5 oz 1% $11.50
1064 Tolnaftate Antifungal Cream 1.25 oz 1% $7.00
COLD SORE & MEDICATED LIP PRODUCTS
1152 Abreva 2 gm 10% $24.00
1256 Blistex Lip Ointment 6 gm - $5.00
1153 Herpecin-L Lip Balm .1 oz 1% $10.00
1359 Releev Cold Sore Treatment 6 ml 0.13% $22.50
DENTAL & DENTURE CARE
1817 Biotene Dry Mouth Oral Rinse 16 oz - $13.00
1747 Denture Brush 1 ct - $6.00
1032 Denture Cleaning Tablets 40 ct - $7.00
1653 Efferdent Plus Mint Tablets 36 ct - $9.00
1843 Effergrip Denture Cream Adhesive 2.5 oz - $9.00
1187 Fixodent .75 oz - $6.50
1751 Interdental Flossups 90 ct - $5.50
1454 Orajel Pain Relief 7 gm 20% $11.00
1286 Oral Pain Relief .5 oz 20% $7.00
1324 Polident Denture Cream 3.9 oz - $9.00
1892 Polident Overnight 84 ct - $12.00
1455 Reach Waxed Dental Floss - Mint 55 yd - $4.00
1746 Tongue Cleaner 1 ct - $6.00
Remember to keep this catalog * ‡ – See Page 16 5
-
Item # Packaging Price Product Strength
1413 Toothbrush, Colgate, Adult Soft 1 ct - $3.00
1450 Toothbrush, Rechargeable 1 ct - $37.00
1412 Toothbrush, Tek Pro, Angled Soft 1 ct - $3.00
1831 Toothpaste, Colgate 4 oz - $6.00
1838 Toothpaste, Crest Sensi-Relief 4.1 oz - $9.50
1414 Toothpaste, Pepsodent 5.5 oz - $4.00
1903 Toothpaste, Sensitive Teeth 4.3 oz - $5.00
1716 Toothpaste, Ultrabrite Advanced Whitening 6 oz - $6.00
1744 Water Jet 1 ct - $45.00
1743 Water Jet Replacement Tips 5 ct - $17.00
DIABETES
1839 Diabetic Skin Relief Foot Cream 3.4 oz - $12.00
1956 Diabetic Socks, Black, Medium 3-pack 3 pair - $9.00
1957 Diabetic Socks, Black, Large 3-pack 3 pair - $9.00
1958 Diabetic Socks, Black, X-Large 3-pack 3 pair - $9.00
1953 Diabetic Socks, White, Medium 3-pack 3 pair - $9.00
1954 Diabetic Socks, White, Large 3-pack 3 pair - $9.00
1955 Diabetic Socks, White, X-Large 3-pack 3 pair - $9.00
EAR CARE
1742 Cotton Tipped Swabs 300 ct - $5.50
1841 Ear Pain Relief Ear Drops 10 ml - $13.00
1190 Ear Wax Removal Drops 15 ml 6.5% $7.00
1363 Ear Wax Removal System with Rubber Bulb 15 ml 6.5% $9.00
EYE CARE
1192 Artiȴcial Tears Drops .5 oz - $6.00
1194 Artificial Tears Ointment 3.5 gm - $9.00
1199 Clear Eyes Eye Drops .2 oz - $6.00
1468 Multi-Purpose Contact Lens Solution 4 oz - $8.00
1061 Redness Relief Eye Drops 15 ml 0.05% $5.00
6 Order Online: www.vitalityotc.net
-
Packaging Price Item # Product Strength
FIRST AID & MEDICAL SUPPLIES
1344 Adhesive Bandages * 60 ct - $6.00
1803 After Bite Relief .5 oz - $10.00
1200 Alcohol Pads * 100 ct 70% $5.00
1808 Antiseptic Skin Cleanser 8 oz - $11.00
1201 Antiseptic Towelettes 100 ct - $7.50
1020 Bacitracin Ointment 1 oz 500 U / gm $6.50
1728 Bath Bench with Back 1 ct - $55.00
1727 Bath Bench without Back 1 ct - $45.00
1459 Bath Mat, Non-Skid 1 ct - $15.00
1730 Bath Tub Safety Rail 1 ct - $38.00
1223 Conforming Stretch Gauze Sterile Bandages -3" x 4.1 yd * 12 ct - $8.00
1763 Cotton Balls 200 ct - $4.50
1669 Cotton Tipped Applicator - 6" 1000 ct - $11.50
1836 CPAP Pillow Fiber Filled 1 ct - $60.00
1732 Cushion, Foam Ring 1 ct - $22.00
1466 Cushion, Gel / Foam Seat 1 ct - $30.00
1731 Cushion, Lumbar 1 ct - $20.00
1207 Elastic Bandage - 2" x 4.5 yd * 1 ct - $6.00
1209 Elastic Bandage - 3" x 5 yd * 1 ct - $6.50
1211 Elastic Bandage - 4" x 5 yd * 1 ct - $7.00
1213 Elastic Bandage - 6" x 5 yd * 1 ct - $8.00
1846 Fast Freeze, Pain Relief Spray 4 oz - $13.50
1215 First Aid Kit, 75 Pieces 1 ct - $10.00
1738 First Aid Kit, 175 Pieces 1 ct - $15.00
1726 Folding Cane Ergonomic Handle * 1 ct - $20.00
1062 Hot/Cold Pack, 1 small & 1 large 1 ct - $9.00
1795 Humidifier, Ultra-Sonic Cool Mist 1 ct - $60.00
1228 Hydrogen Peroxide 16 oz 3% $5.00
1796 Insect Repellant Spray - Deet 4 oz 30% $12.00
Remember to keep this catalog * ‡ – See Page 16 7
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Packaging Price Item # Product Strength
1229 Isopropyl Alcohol, Wintergreen 16 oz 70% $6.50
1798 Knurled Chrome Grab Bar - 12" 1 ct - $19.00
1797 Knurled Chrome Grab Bar - 24" 1 ct - $22.00
1202 Lantiseptic Skin Protectant Ointment 4 oz 50% $12.00
1326 Neosporin Plus .5 oz - $10.00
1840 Nitrile Exam Gloves 100 ct - $12.00
1203 Povidone Iodine Solution Antiseptic 4 oz - $7.50
1777 Quad Cane, Small Base * 1 ct - $25.00
1776 Quad Cane, Large Base * 1 ct - $28.00
1729 Raised Toilet Seat 1 ct - $35.00
1713 Rubbing Alcohol 16 oz 70% $6.00
1460 Shower Mat, Non-Skid 1 ct - $17.50
1217 Tape, Paper Surgical - 1" x 10 yd * 1 ct - $6.00
1218 Tape, Paper Surgical - 2" x 10 yd * 1 ct - $7.00
1219 Tape, Silk Surgical - 1" x 10 yd * 1 ct - $5.50
1220 Tape, Silk Surgical - 2" x 10 yd * 1 ct - $7.50
1221 Tape, Transparent Surgical - 1" x 10 yd * 1 ct - $5.50
1222 Tape, Transparent Surgical - 2" x 10 yd * 1 ct - $7.00
1063 Thermometer, Digital 60 seconds 1 ct - $6.50
1285 Thermometer, Digital Ear 1 ct - $25.00
1697 Thermometer, Flexible Tip, Digital 10 seconds 1 ct - $11.00
1925 Thermometer, Talking Ear and Forehead 1 ct - $50.00
1779 Toilet Safety Rails 1 set - $40.00
1014 Triple Antibiotic Ointment 1 oz - $8.00
FOOT CARE
1238 Callus Remover Pads 6 ct - $8.00
1236 Corn Remover Pads 9 ct - $7.50
1240 Medicated Foot Powder 5 oz - $7.50
HEMORRHOIDAL PREPARATIONS
1066 Hemorrhoidal Ointment 2 oz - $9.00
8 Order Online: www.vitalityotc.net
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Packaging Price Item # Product Strength
1247 Hemorrhoidal Suppository 12 ct - $7.00
1364 Pre-moist Hemorrhoid Pads 100 ct - $9.00
1248 Preparation H Cream 26 gm - $12.00
1895 Preparation H Medicated Wipes 48 ct - $11.00
HORMONE REPLACEMENT
1737 DHEA ‡ 50 ct 50 mg $12.00
INCONTINENCE SUPPLIES
1300 A & D Ointment 2 oz - $7.00
1303 Adult Briefs, Medium - 32" to 44" * 12 ct - $16.00
1304 Adult Briefs, Large - 45" to 58" * 12 ct - $16.00
1305 Adult Briefs, X-Large - 59" to 64" * 15 ct - $16.00
1811 Attends Discreet Men's Guard 20 ct - $14.00
1810 Attends Discreet Men's Shield 20 ct - $13.00
1813 Attends Discreet Women's Moderate Bladder Control Pad 20 ct - $15.50
1812 Attends Discreet Women's Maximum Bladder Control Pad 20 ct - $20.00
1814 Attends Discreet Women's Ultimate Bladder Control Pad 20 ct - $22.00
1815 Attends Discreet Women's Panty Liner 28 ct - $9.00
1816 Attends Discreet Women's Ultrathin Pad 20 ct - $11.00
1302 Barrier Cream 4 oz - $9.00
1478 Bladder Control Shaped Pad, Moderate Absorbency * 24 ct - $17.00
1479 Bladder Control Shaped Pad, Heavy Absorbency * 24 ct - $17.00
1480 Bladder Control Shaped Pad, Maximum Absorbency * 18 ct - $17.00
1021 Disposable Underwear, Medium - 34” to 44” * 20 ct - $16.00
1026 Disposable Underwear, Large - 44” to 58” * 18 ct - $16.00
1027 Disposable Underwear, X-Large - 58” to 68” * 14 ct - $16.00
1928 Flushable Wipes 24 ct - $8.00
1476 Underpad, Disposable - 23" x 24" * 50 ct - $16.00
1299 Underpad, Disposable - 23" x 36" * 25 ct - $12.00
Remember to keep this catalog * ‡ – See Page 16 9
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Item # Packaging Product Strength Price
1477 Underpad, Disposable - 30" x 30" * 10 ct - $10.00
1348 Washcloth with Lanolin 64 ct - $8.50
MOTION SICKNESS
1263 Driminate Antiemetic 12 ct 50 mg $7.00
1366 Meclizine HCL Antiemetic 100 ct 12.5 mg $9.00
PAIN RELIEVERS & FEVER REDUCERS
1001 Acetaminophen 100 ct 325 mg $6.50
1600 Acetaminophen 100 ct 500 mg $7.00
1104 Aleve 100 ct 220 mg $17.25
1311 Arthritis Pain Reliever 100 ct 650 mg $12.00
1095 Aspirin 100 ct 325 mg $5.50
1096 Aspirin, Enteric Coated 100 ct 325 mg $6.00
1002 Aspirin, Enteric Coated, Low Dose 120 ct 81 mg $6.00
1802 Aspirin, Low Dose, Chewables 36 ct 81 mg $5.50
1367 Capsaicin External Analgesic 2 oz 0.025% $9.50
1980 Eagle Brand Medicated Oil 36 ml 14.5%, 30% $11.50
1861 Heating Pad, 12” X 15” * 1 ct - $26.00
1859 HeatWraps - Back & Hip 2 ct - $11.00
1860 HeatWraps - Neck, Shoulder, & Wrist 3 ct - $11.00
1004 Ibuprofen 100 ct 200 mg $8.00
1871 Lidocaine Patch 5 ct 4% $13.00
1923 Menthol Gel 8 oz 2% $9.00
1365 Migraine Relief 100 ct 250 mg, 250 mg, 65 mg $8.00
1097 Naproxen 100 ct 220 mg $10.00
1332 Pain Reliever, PM - Extra Strength 100 ct 500 mg, 25 mg $9.00
1475 Pain Relieving Muscle Rub 2 oz 2.5% $6.00
1739 Salonpas Pain Relief Patches 5 ct - $14.00
1979 Tiger Balm Ultra Strength Ointment .63 oz 11% $10.00
1261 Wellpatch Migraine 4 ct - $10.00
10 Order Online: www.vitalityotc.net
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* ‡ – See Page 16 11
Item # Packaging Price Product Strength
PEDICULICIDE (LICE TREATMENT)
1929 Lice Elimination Kit 1 kit - $29.00
1271 Lice Treatment Shampoo 4 oz - $11.00
1269 Permethrin Lice Treatment 59 ml 1% $16.00
PERSONAL CARE
1076 Acne Gel 10% Benzoyl Peroxide 1.5 oz 10% $8.50
1368 Ammonium Lactate Moisturizing Lotion 8 oz 12% $12.00
1065 Hand Sanitizer 8 oz - $4.50
SLEEP AIDS
1724 Nasal Strips, Medium 30 ct - $13.00
1725 Nasal Strips, Large 30 ct - $13.00
1276 Sleep Tablets 50 ct 25 mg $7.50
SMOKING CESSATION
1372 Nicorelief Gum ‡ 50 ct 4 mg $25.00
1281 Nicotine Lozenges ‡ 72 ct 4 mg $42.00
1369 Nicotine Patch, Step 1 ‡ 14 ct 21 mg / 24 hr $35.00
1370 Nicotine Patch, Step 2 ‡ 14 ct 14 mg / 24 hr $35.00
1371 Nicotine Patch, Step 3 ‡ 14 ct 7 mg / 24 hr $35.00
SUPPORTIVE ITEMS
1225 Ankle Support 1 ct - $10.00
1767 Arthritis Gloves, Small 1 pair - $27.00
1766 Arthritis Gloves, Medium 1 pair - $27.00
1765 Arthritis Gloves, Large 1 pair - $27.00
1487 Back Support Elastic - 24" to 46" 1 ct - $23.00
1488 Back Support Elastic with Lumbar 1 ct - $27.00
1770 Carpal Tunnel Brace, Small 1 ct - $25.00
1769 Carpal Tunnel Brace, Medium 1 ct - $25.00
1768 Carpal Tunnel Brace, Large 1 ct - $25.00
Remember to keep this catalog
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Item # Price Product Packaging Strength
1398 Compression Knee High Socks, Men's Black, Medium (Shoe Size 8 - 10) ‡ 1 pair 15 - 20 mmHg $18.00
1399 Compression Knee High Socks, Men's Black, Large (Shoe Size 10.5 - 12) ‡ 1 pair 15 - 20 mmHg $18.00
1400 Compression Knee High Socks, Men's White, Medium (Shoe Size 8 - 10) ‡ 1 pair 15 - 20 mmHg $18.00
1401 Compression Knee High Socks, Men's White, Large (Shoe Size 10.5 - 12) ‡ 1 pair 15 - 20 mmHg $18.00
1409 Compression Knee High Socks, Women's Black, Small (Shoe Size 4-5) 1 pair 8 - 15 mmHg $18.00
1410 Compression Knee High Socks, Women's Black, Medium (Shoe Size 5.5 - 7.5) 1 pair 8 - 15 mmHg $18.00
1411 Compression Knee High Socks, Women's Black, Large (Shoe Size 8 - 10.5) 1 pair 8 - 15 mmHg $18.00
1406 Compression Knee High Socks, Women's Nude, Small (Shoe Size 4 - 5) 1 pair 8 - 15 mmHg $18.00
1407 Compression Knee High Socks, Women's Nude, Medium (Shoe Size 5.5 - 7.5) 1 pair 8 - 15 mmHg $18.00
1408 Compression Knee High Socks, Women's Nude, Large (Shoe Size 8 - 10.5) 1 pair 8 - 15 mmHg $18.00
1760 Deluxe Criss Cross Back Support, Small - 28" to 32" 1 ct - $24.00
1759 Deluxe Criss Cross Back Support, Medium - 33" to 37" 1 ct - $24.00
1758 Deluxe Criss Cross Back Support, Large - 38" to 42" 1 ct - $24.00
1224 Elbow Support 1 ct - $15.00
1862 Hip Protector, Small 1 ct - $46.00
1863 Hip Protector, Medium 1 ct - $46.00
1864 Hip Protector, Large 1 ct - $46.00
1865 Hip Protector, X-Large 1 ct - $46.00
1936 Hypoallergenic Pillow 1 ct - $55.00
1465 Knee Stabilizer 1 ct - $23.00
1481 Knee Support, Elastic, Small 1 ct - $11.00
1482 Knee Support, Elastic, Medium 1 ct - $11.00
1483 Knee Support, Elastic, Large 1 ct - $11.00
1484 Knee Support, Elastic, Small with Stays 1 ct - $19.00
1485 Knee Support, Elastic, Medium with Stays 1 ct - $19.00
12 Order Online: www.vitalityotc.net
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Packaging Price Item # Product Strength
1486 Knee Support, Elastic, Large with Stays 1 ct - $19.00
1463 Night Wrist Support Smart Glove 1 ct - $30.00
1457 Rib Belt - Female (one size ȴts most) 1 ct - $19.00
1456 Rib Belt - Male (one size ȴts most) 1 ct - $19.00
1230 Wrist Splint 1 ct - $22.00
1227 Wrist Support 1 ct - $10.00
THERAPEUTIC SKIN & SUN CARE
1821 Calamine Lotion 6 oz - $7.00
1893 Moisturizing Body Lotion with Aloe 8 oz - $7.50
1852 Scar Gel 50 gm - $15.00
1284 Sunscreen Lotion SPF 30 3.5 oz - $7.50
VITAMINS & MINERALS
1805 Airborne Immune Support Chewables ‡ 32 ct - $16.00
1820 Biotin Gummy ‡ 60 ct 5,000 mcg $13.00
1373 Calcium + Vitamin D ‡ 60 ct 600 mg / 400 u $7.00
1823 Calcium + Vitamin D Gummy ‡ 60 ct 500 mg, 1000 IU $13.00
1291 Calcium Carbonate Supplement Tablets ‡ 60 ct 600 mg $7.00
1420 Centrum Silver Chewables ‡ 60 ct - $18.00
1829 Coenzyme Q-10 ‡ 30 ct 50 mg $12.00
1385 Daily Multiple Vitamin Tablets with Minerals ‡ 100 ct - $8.50
1393 Daily Multivitamin ‡ 100 ct - $8.00
1375 Ferrous Gluconate Iron Supplement ‡ 100 ct 240 mg $7.50
1376 Ferrous Sulfate Iron Supplement ‡ 100 ct 325 mg $7.50
1155 Fiber Tablets ‡ 60 ct 500 mg $10.00
1741 Fish Oil, Soft Gels ‡ 60 ct 1000 mg $8.00
1849 Flaxseed ‡ 100 ct 1000 mg $11.00
1850 Folic Acid ‡ 100 ct 800 mcg $6.50
1003 Glucosamine / Chondroitin ‡ 60 ct 250 mg, 200 mg $12.00
1114 Glucosamine Joint / Muscle ‡ 60 ct 500 mg $11.00
1866 Immune Support Chewables ‡ 50 ct - $11.50
Remember to keep this catalog * ‡ – See Page 16 13
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Item # Packaging Price Product Strength
1417 Iron ‡ 110 ct 27 mg $8.00
1869 Leg Cramps Pain Relief Caplets ‡ 50 ct - $14.00
1418 Magnesium ‡ 110 ct 250 mg $7.00
1377 Magnesium Oxide ‡ 100 ct 250 mg $8.00
1879 Melatonin ‡ 100 ct 5 mg $12.00
1378 Niacin ‡ 100 ct 100 mg $6.00
1886 One Daily Men’s Multivitamin ‡ 100 ct - $10.00
1887 One Daily Women’s Multivitamin ‡ 100 ct - $10.00
1395 Rena-Vite ‡ 100 ct - $13.50
1392 Senior Multivitamin ‡ 90 ct - $11.00
1734 Stress Formula Tablets with Zinc ‡ 60 ct - $10.00
1379 Vitamin A ‡ 100 ct 10,000 iu $8.00
1016 Vitamin B-1 ‡ 100 ct 100 mg $7.50
1381 Vitamin B-12 ‡ 100 ct 1000 mcg $11.00
1388 Vitamin B-6 ‡ 100 ct 100 mg $8.00
1382 Vitamin B-Complex ‡ 100 ct - $8.00
1915 Vitamin B-Complex Gummy ‡ 70 ct - $13.00
1017 Vitamin C ‡ 100 ct 500 mg $7.50
1916 Vitamin C Gummy ‡ 60 ct 250 mg $12.00
1390 Vitamin D ‡ 100 ct 1000 iu $9.00
1384 Vitamin E, Soft Gels ‡ 100 ct 400 iu $11.00
1419 Zinc Chelated ‡ 100 ct 50 mg $7.00
WART REMOVER
1288 Dr. Scholl's Wart Removal System 20 ct - $15.00
1075 Wart Remover, Liquid 9 ml 17% $10.00
1289 Wartners Wart Removal System 1 ct - $19.00
WEIGHT LOSS
1735 Vitafusion Fiber Weight Management ‡ 90 ct - $17.50
14 Order Online: www.vitalityotc.net
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ORDER GUIDELINES ORDER ONLINE You may place an order online using your Vitality Health Plan of California OTC website at www.vitalityotc.net. Remember to save your username and password to order again during your next benefit period.
ORDER BY MAIL You may place your order by mailing in the order form that comes with your catalog. If the end of the benefit period is approaching and you do not think your order form will be
received in time, you may order online or call in your order.
ORDER BY PHONE If you have questions or would like to place an order over the phone, OTC Advocates are available Monday – Friday from 8:00 a.m. to 11:00 p.m. EST at 1-877-906-8273 (TTY: 711).
• For delivery, please allow 7 - 10 business days from the time your order is placed.
• You must use your full benefit amount in one order.
• Your order total may not exceed your benefit amount. Cash, checks, credit cards or money orders are not accepted under this OTC benefit.
• Your order total will be applied to the benefit period in which the order is received.
• OTC products are intended for member use only to help with a health or medical need. Vitality Health Plan of California prohibits the use of this benefit to order OTC items for family members and friends.
• Due to the personal nature of these products, returns are not accepted.
• Items in the 2019 OTC catalog may change throughout the year. For the most up-to-date listing of OTC products available, go to www.vitalityotc.net
• OTC items are available through home delivery only. Products may not be purchased at a local retail pharmacy or through any source other than the Vitality Health Plan of California OTC benefit channels listed above.
Remember to keep this catalog * ‡ – See Page 16 15
http://www.vitalityotc.nethttp://www.vitalityotc.net
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NOTICES • If you disenroll from Vitality Health Plan of California, your OTC benefit will also terminate.
• Vitality Health Plan of California is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.
• This information is available for free in other languages. Please call Vitality Member Service Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30.
• The health information provided in the catalog is general in nature and is not medical advice or a substitute for professional health care.
* Part B/D - Under certain circumstances some items may be covered under either Part B or Part D. When you are eligible to receive these items under Part B or Part D you may not purchase these items through your Part C supplemental OTC benefit. For your convenience, we’ve marked these items with an (*)
‡ Dual-purpose items are medicines and products that can be used for either a medical condition or for general health and well-being. In order to purchase these items under your plan, your personal physician must recommend them to you for a specific diagnosed condition. Please speak to your physician before ordering these items.
16 Order Online: www.vitalityotc.net
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2019 OVER–THE–COUNTER (OTC) PRODUCT
ORDER FORM
STEP 1 - COMPLETE YOUR INFORMATION BELOW Member ID (found on plan member ID card) Date of Birth
First Name Last Name MI
Street Number Street Name Apt/Suite #
City State Zip Code
Daytime Phone Email (Optional) Please check box if this is a new address
@ .
STEP 2 - PRODUCT SELECTION
Cash, checks, credit cards or money orders are not accepted under this OTC benefit.
Item # Product Quantity Unit Price TOTAL
1 $ . $ .
2 $ . $ .
3 $ . $ .
4 $ . $ .
5 $ . $ .
Subtotal from Other Side $ .
Total Order $ .
To order additional products, please see reverse. Please mail the completed form back in the postage-paid envelope provided.
If you place your order using an order form, your order total will be applied to the month in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order WRWDO�ZLOO�EH�DSSOLHG�WR�\RXU�-XO\�EHQH LW��QRW�\RXU�-XQH�EHQH LW�
H1426_19_082_MK_ENG_C�$SSURYHG
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STEP 2 - PRODUCT SELECTION (Continued)
Cash, checks, credit cards or money orders are not accepted under this OTC benefit.
Item # Product Quantity Unit Price TOTAL
6 $ . $ .
7 $ . $ .
8 $ . $ .
9 $ . $ .
10 $ . $ .
11 $ . $ .
12 $ . $ .
13 $ . $ .
14 $ . $ .
15 $ . $ .
16 $ . $ .
17 $ . $ .
18 $ . $ .
19 $ . $ .
20 $ .
$ .
Subtotal $ .
H1426_19_082_MK_ENG_C�$SSURYHG
To order additional products, please see reverse. Please mail the completed form back in the postage-paid envelope provided.
If you place your order using an order form, your order total will be applied to the month in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order WRWDO�ZLOO�EH�DSSOLHG�WR�\RXU�-XO\�EHQHILW��QRW�\RXU�-XQH�EHQHILW�
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H1426_19_063_MK_ENG_C Approved
_________________________________
DENTAL BENEFITS
VITALITY HEALTH PLAN OF CALIFORNIA, INC.
Vitality Choice (HMO)
Administered by: �� � � �
�� � � � � � � � � �������
� � � � � � � � � � � � � � �����
�� � � � � � � �
� � � � � � � � Delta Dental of California
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Evidence of Coverage for Delta Dental of California
Vitality Choice (HMO) Dental Benefits�
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Table of Contents
Introduction ........................................................................................................................ 1
Definitions ................................ .......................................................................................... 1
How to use this Plan - Choice of Participating Provider..................................................... 3
Continuity of Care ................................................ .............................................................. 4
Facility Accessibility ..................................... ..................................................................... 4
Benefits, Limitations and Exclusions .................................................................................. 4
Copayments and Other Charges .......................................................................................... 4
Emergency Services ............. .............................................................................................. 5
Specialist Services ............. ................................................................................................. 5
Second Opinion ................................................................................................................... 5
Claims for Reimbursement ................. ................................................................................ 6
Provider Compensation ....................................................................................................... 6
Processing Policies .............................................................................................................. 6
Coordination of Benefits ............... ..................................................................................... 7
Grievance and Appeals Process........................................................................................... 7
Renewal and Termination of Benefits ...................... .......................................................... 7
Cancellation of Enrollment.................. ............................................................................... 8
Schedule A - Description of Benefits and Copayments .. ................................................... 9
Schedule B - Limitations and Exclusions of Benefits....................................................... 17
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INTRODUCTION
We are pleased to welcome you to the dental plan for Vitality Health Plan of California, Inc. Your plan is administered by Delta Dental of California (“Delta Dental”). Our goal is to provide you with high quality dental care and to help you maintain good dental health. We encourage you not to wait until you have a problem to see the dentist, but to see him/her on a regular basis.
This plan is available in the following counties: Santa Clara and San Joaquin counties.�
Using This Evidence of Coverage
This Dental Benefit Addendum (“Plan”), which includes Attachment A, Schedule of Copayments and, Attachment B, Services, Limitations and Exclusions, discloses the terms and conditions of your coverage and is designed to help you make the most of your dental plan. It will help you understand how the Plan works and how to obtain dental care. Please read this booklet completely and carefully. Please read the Definitions section, which will explain any words that have special or technical meanings in this Plan.
The benefit explanations contained in this Plan booklet are subject to all provisions of the Contract on file with Vitality Health Plan of California, Inc. (“Contract holder”) and do not modify the terms and conditions of the Contract in any way, nor shall you accrue any rights because of any statement in or omission from this booklet.
Notice: This Plan booklet is a summary of your dental plan and its accuracy should be verified before receiving treatment. This information is not a guarantee of covered Benefits, services or payments.
Contact Us
For more information please visit www.VitalityHP.net or call Delta Dental’s Customer Service Center at (866) 241-6833 (TTY 711). A Customer Service Representative can answer questions you may have about obtaining dental care, help you locate a Delta Dental Participating Provider, explain Benefits, check the status of a claim, and assist you in filing a claim.
You can access Delta Dental’s automated information line at (866) 241-6833 (TTY 711) during regular business hours to obtain information about Member’s eligibility and Benefits, or claim status, or to speak to a Customer Service Representative for assistance. If you prefer to write Delta Dental with your question(s), please mail your inquiry to the following address:
Delta Dental 1130 Sanctuary Parkway Alpharetta, GA 30009
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www.VitalityHP.net
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DEFINITIONS
Terms when capitalized in this Plan booklet have defined meanings, given in the section below or throughout the booklet sections.
Appeal is something you do if you disagree with a decision to deny a request for dental care services or payment for services you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask Vitality Health Plan of California for an appeal if our Plan doesn’t pay for a service you think you should be able to receive.
Benefits - the dental services under this Plan to which you are entitled to receive.
Calendar Year - the 12 months of the year from January 1st through December 31st.
Claim Form - the standard form used to file a claim or request a Pre-Treatment Estimate.
Contract - the Agreement between Vitality Health Plan of California, Inc. and Delta Dental of California for the Provision of Dental Services.
Contract holder – Vitality Health Plan of California, Inc.
Cost-sharing – the amounts which may be charged to a Member as the Member’s share of the cost for the provision of covered services. Cost sharing under this Plan consists of copayments listed in Attachment A.
Delta Dental Participating Provider (Participating Provider) – means a person licensed to practice dentistry when and where performed who has entered into a contract with Delta Dental agreeing to participate in this Plan and provide covered services in general dentistry to Members.
Emergency Service - dental care furnished to a Member needed to treat a dental condition which manifests as a symptom of sufficient severity, including severe pain, such that the absence of immediate attention could reasonably be expected by the Member to result in either: (i) placing the Member's dental health in serious jeopardy, or (ii) serious impairment to dental functions.
Effective Date – means the original date the Plan starts. This date is given on this booklet’s cover and Attachment A.
Grievance – A grievance is any complaint or dispute expressing dissatisfaction with any aspect of the operations, activities, or behavior of Vitality Health Plan of California, or its providers, such as Delta Dental, regardless of whether remedial action is requested.
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Member – a person with Medicare who is eligible to get covered services, who has enrolled in the Plan and whose enrollment has been confirmed by CMS.
Non Participating Provider -- a dentist who has not entered into an agreement with Delta Dental to be a Participating Provider under this Plan.
Plan - this dental plan which describes the Benefits, limitations, exclusions, terms and conditions of coverage for Members enrolled in Contract holder’s Medicare Advantage Plan.
Plan Year - the 12 months starting on the Effective Date and each subsequent 12-month period thereafter.
Pre-Treatment Estimate - an estimation of the allowable Benefits under the Plan for the services proposed.
Procedure Code - the Current Dental Terminology® (CDT) number assigned to a Single Procedure by the American Dental Association.
Reasonable - means that a Member exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact his/her Participating Provider to obtain Emergency Services and, in the event the Participating Provider is not available, makes at least one attempt to contact Delta Dental for assistance before seeking care from another Participating Provider.
Single Procedure - a dental procedure that is assigned a separate Procedure Code.
Specialist Services - mean services performed by a licensed dentist who specializes in the practice of oral surgery, endodontics, periodontics or pediatric dentistry, and which must be preauthorized in writing by Delta Dental.
Treatment in Progress - means any single dental procedure, as defined by the Procedure Code that has been started while the Member was eligible to receive Benefits, and for which multiple appointments are necessary to complete the procedure whether or not the Member continues to be eligible for Benefits under the Plan. Examples include: teeth that have been prepared for crowns, root canals where a working length has been established, full or partial dentures for which an impression has been taken.
How to use this Plan - Choice of Participating Provider
To receive Benefits under this Plan, you must select a Participating Provider from the directory of Participating Providers. If you fail to select a Participating Provider or the Participating Provider selected by you becomes unavailable, we will request you select another Participating Provider or we will assign you to a Participating Provider. You may change your assigned Participating Provider by directing a request to the Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711). In
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order to ensure that your Participating Provider is notified and our eligibility lists are correct, changes in Participating Providers must be requested prior to the 21st of the month for changes to be effective the first day of the following month.
Shortly after enrollment you will receive a membership packet that tells you the effective date of your Plan and the address and telephone number of your Participating Provider. After the effective date in your membership packet, you may obtain dental services under the Plan. To make an appointment simply call your Participating Provider's facility and identify yourself as a Member through Vitality Health Plan of California, Inc. Inquiries regarding availability of appointments and accessibility of Participating Providers should be directed to the Customer Service department at (866) 241-6833 (TTY users 711).
EACH MEMBER MUST GO TO HIS OR HER ASSIGNED PARTICIPATING PROVIDER TO OBTAIN COVERED SERVICES, EXCEPT EMERGENCY SERVICES OR SERVICES PROVIDED BY A SPECIALIST, WHICH MUST BE PREAUTHORIZED IN WRITING BY DELTA DENTAL. ANY OTHER TREATMENT IS NOT COVERED UNDER THIS PLAN.
If your assigned Participating Provider's agreement with Delta Dental terminates, that Participating Provider will complete (a) a partial or full denture for which final impressions have been taken, and (b) all work on every tooth upon which work has started (such as completion of root canals in progress and delivery of crowns when teeth have been prepared).
Continuity of Care
Existing Members:
You may have the right to have completion of care with your terminated Participating Provider for certain specified dental conditions. Please call Customer Service at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711) to see if you may be eligible for this benefit. You may request a copy of our Continuity of Care Policy. You must make a specific request to continue under the care of your terminated Participating Provider. We are not required to continue your care with that Participating Provider if you are not eligible for coverage under the Plan or if we cannot reach agreement with your terminated Participating Provider on the terms regarding your care.
New Members:
You may have the right to the qualified benefit of completion of care with a Non Participating Provider for certain specified dental conditions. Please call the Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711) to see if you may b e eligible for this benefit. You may request a copy of our Continuity of Care Policy. You must make a specific request to continue under the care of your current Non Participating Provider. We are not required to continue your care with that dentist if you are not eligible under the Plan or if we cannot reach agreement with your dentist on the terms regarding your care.
Facility Accessibility
Many facilities provide Delta Dental with information about special features of their offices, including accessibility information for patients with mobility impairments. To obtain information
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regarding facility accessibility, contact Delta Dental's Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711).
Benefits, Limitations and Exclusions
This Plan provides the Benefits described in Attachment A, Description of Benefits and Copayments subject to the limitations and exclusions described in Attachment B. The services are performed as deemed appropriate by your attending Participating Provider. A Participating Provider may provide services either personally or through associated dentists, technicians or hygienists who may lawfully perform the services.
Copayments and Other Charges
You are required to pay any Copayments listed in the Attachment A, Description of Benefits and Copayments directly to the Participating Provider or Specialist who provides treatment. Charges for broken appointments (unless notice is received by the dentist at least 24 hours in advance or an emergency prevented such notice), and charges for visits after normal visiting hours are listed in the Description of Benefits and Copayments.
Emergency Services
If Emergency Services are needed, you should contact your Participating Provider whenever possible. If you are a new Member needing Emergency Services, but do not have an assigned Participating Provider yet, contact Delta Dental's Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711) for help in locating a Participating Provider. Benefits for Emergency Services by a Non Participating Provider are limited to necessary care to stabilize your condition and/or provide palliative relief when you:
1) have made a Reasonable attempt to contact the Participating Provider and the Participating Provider is unavailable or you cannot be seen within 24 hours of making contact; or
2)
have made a Reasonable attempt to contact Delta Dental prior to receiving Emergency Services, or it is Reasonable for you to access Emergency Services without prior contact with Delta Dental; or
3) reasonably believe that your condition makes it dentally/medically inappropriate to travel to the Participating Provider to receive Emergency Services.
Benefits for Emergency Services not provided by the Participating Provider are limited to a maximum of $100.00 per emergency less the applicable Copayment. If the maximum is exceeded, or the above conditions are not met, you are responsible for any charges for services by a dentist other than your Participating Provider.
Specialist Services
Specialist Services must be referred by the assigned Participating Provider and preauthorized in writing by Delta Dental. All preauthorized Specialist Services will be paid by us less any applicable Copayments.
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You may request a second opinion if you disagree with or question the diagnosis and/or treatment plan determination made by your Participating Provider. Delta Dental may also request that you obtain a second opinion to verify the necessity and appropriateness of dental treatment or the application of Benefits.
Second opinions will be rendered by a licensed dentist in a timely manner, appropriate to the nature of your condition. Requests involving cases of imminent and serious health threat will be expedited (authorization approved or denied within 72 hours of receipt of the request, whenever possible). For assistance or additional information regarding the procedures and timeframes for second opinion authorizations, contact Delta Dental's Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711) or write to Delta Dental.
Second opinions will be provided at another Participating Provider's facility, unless otherwise authorized by Delta Dental. Delta Dental will authorize a second opinion by a Non Participating Provider if an appropriately qualified Participating Provider is not available. Delta Dental will only pay for a second opinion which Delta Dental has approved or authorized. You will be sent a written notification should Delta Dental decide not to authorize a second opinion. If you disagree with this determination, you may file an Appeal with Bright Health. Please refer to the section of this booklet titled “Grievance and Appeals Process” below for an explanation of how to file an Appeal.
Claims for Reimbursement
Claims for Emergency Services or preauthorized Specialist Services should be submitted to Delta Dental within 90 days of the end of treatment. Valid claims received after the 90-day period will be reviewed if you can show that it was not reasonably possible to submit the claim within that time. The address for claims submission is Claims Department, P. O. Box 1810, Alpharetta, GA 30023.
Provider Compensation
A Participating Provider is compensated by Delta Dental through monthly capitation (an amount based on the number of Members assigned to the Participating Provider), and by Members through required Cost Sharing for treatment received. A Specialist is compensated by Delta Dental through an agreed-upon amount for each covered procedure, less the applicable Copayment paid by the Member. In no event does Delta Dental pay a Participating Provider or a Specialist any incentive as an inducement to deny, reduce, limit or delay any appropriate treatment.
In the event we fail to pay a Participating Provider, you will not be liable to that Participating Provider for any sums owed by us. The Participating Provider’s contract with Delta Dental contains a provision prohibiting the Participating Provider from charging a Member for any sums owed by Delta Dental. Except for the provisions in Emergency Services, if you have not received Preauthorization for treatment from a Non Participating Provider or Specialist, and we fail to pay that dentist you may be liable to that dentist for the cost of services.
You may obtain further information concerning compensation by calling Delta Dental at the toll-free telephone number listed in this booklet.
Processing Policies
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The dental care guidelines for the Plan explain to Participating Providers what services are covered under the dental Contract. Participating Providers will use their professional judgment to determine which services are appropriate for the Member. Services performed by the Participating Provider that fall under the scope of Benefits of the dental Plan are provided subject to any Copayments. If a Participating Provider believes that a Member should obtain treatment from a Specialist, the Participating Provider contacts Delta Dental for a determination of whether the proposed treatment is a covered benefit. Delta Dental will also determine whether the proposed treatment requires treatment by a Specialist. A Member may contact Delta Dental's Customer Service department at (866) 241-6833 Monday through Sunday from 8 a.m. to 8 p.m., 7 days a week (TTY users call 711) for information regarding the dental care guidelines for the Plan.
Coordination of Benefits
This Plan provides Benefits without regard to coverage by any other group insurance policy or any other group health benefits Plan if the other policy or Plan covers services or expenses in addition to dental care. Otherwise, Benefits provided under this Plan by Specialists or Non Participating Providers are coordinated with such other group dental insurance policy or any group dental benefits Plan. The determination of which policy or Plan is primary shall be governed by the rules stated in the Contract.
If this plan is secondary, it will pay the lesser of:
- the amount that it would have paid in the absence of any other dental benefit coverage, or
- the enrollee's total out-of-pocket cost payable under the primary dental benefit plan.
A Member must provide to Delta Dental and Delta Dental may release to or obtain from any insurance company or other organization, any information about the Member that is needed to administer coordination of benefits. Delta Dental shall, in its sole discretion, determine whether any reimbursement to an insurance company or other organization is warranted under these coordination of benefits provisions, and any such reimbursement paid shall be deemed to be Benefits under this Plan. Delta Dental will have the right to recover from a dentist, Member, insurance company or other organization, as Delta Dental chooses, the amount of any Benefits paid by Delta Dental which exceeds its obligations under these coordination of benefit provisions.
Grievance and Appeals Process
Our commitment to you is to ensure not only quality of care, but also quality in the treatment process. This quality of treatment extends from the professional services provided by Participating Providers to the courtesy extended you by our telephone representatives. If you have any question or complaint regarding eligibility, the denial of dental services or claims, the policies, procedures or operations of Delta Dental or the quality of dental services performed by a Participating Provider, you have the right to file a grievance or appeal with Vitality Health Plan of California, Inc. See your Vitality Health Plan of California, Inc. Evidence of Coverage Booklet for informa