CoreSource PPO Plan - Post July 1, 2004 Retirees

CoreSource PPO Plan
Group Number: 4138
Customer Service: 866-280-4120
Website: www.coresource.com
Contracting Provider Network for California residents: www.anthem.com/ca *
Contracting Provider Network for Non-California residents: www.phcs.com

*(If you are traveling outside the state of California and you need to access medical care, you can access a list of Multiplan contracted providers at www.multiplan.com)

RX Coverage under the CoreSource PPO Plan is provided by:

Caremark
Member Services: 866-772-9436
Group Number: 13940
Website: www.caremark.com

Vision Coverage under the CoreSource PPO Plan applies to retirees who retired on or after July 1, 2004 and is provided by:

UnitedHealthCare Vision
Group Number: 4138 (Corresponds to medical group number)
Member Services: 800-638-3120
Provider Locater: 800-839-3242
Website: http://www.myuhcvision.com/

Claims are reimbursed through UnitedHealthCare Vision at:

UnitedHealthCare Vision

Claims Department
PO Box 30978
Salt Lake City, UT 84130

FAX: 248.733.6060

Dependents are covered up to age 26 with no full time student status (dependent child must be an IRS dependent). Same and opposite sex domestic partner coverage is available.

Resources

CoreSource PPO - Frequently Asked Questions

CoreSource PPO Summaries (Post July 1, 2004 Retirees)

Benefit Summary

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This is the CoreSource PPO Benefit Summary for retirees who retired on or after July 1, 2004. Refer to the Summary Plan Description for a complete listing of benefits, limitations and/or exclusions. This document is for illustration purposes only.

File size: 132 K

Summary Plan Description (2008)

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This is the CoreSource Summary Plan Description for retirees who retired on or after July 1, 2004.

File size: 526 K

Amendment #1 to SPD

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Amendment #1 to SPD. Please download the Summary Plan Description PLUS Amendment #1 and Amendment #2. The three combined documents wrap around to form a complete Plan Document.

File size: 258 K

Amendment #2 to SPD

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Amendment #2 to SPD. Please download the Summary Plan Description PLUS Amendment #1 and Amendment #2. The three combined documents wrap around to form a complete Plan Document.

File size: 806 K

CoreSource PPO Downloads

CoreSource PPO - Claim Form

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This is the CoreSource PPO Medical Claim Form. You must complete claim forms and file claims to receive payment (Note, you MUST file your claims in a timely fashion, failure to file a claim in a timely fashion WILL result in the claim being denied and the entire claim will be your financial responsibility.)

File size: 31 K

CoreView Participant Instructions

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Check it out!! These are the CoreView Participant Instructions. CoreView is a service for CoreSource PPO Plan participants that makes personalized health plan information available 24 hours a day, 7 days a week. From a secure website, you can access detailed claim data, track out-of-pocket expenses, update contact information and more.

File size: 47 K

CoreSource PPO - Pre-Admission Review Process

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CoreSource Healthcare Management is a program that monitors a proposed inpatient hospital stay to help assure that any treatment is medically necessary and appropriate.

The Pre-Admission Review Process is REQUIRED for all hospital visits -- failure to obtain pre-certification may result in additional out of pocket charges.

File size: 48 K

CoreSource PPO Decision Support Tools

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This is the CoreSource PPO Decision Support Tools Brochure.

File size: 138 K