Make the Most of Your Medical Coverage

You have more options than ever for where and how to get quality care. Understanding the type of care you need can save you time, money and stress.

The information below details when to seek each type of care and the options available to you.

Whether you are looking for a primary care provider (PCP), specialist or acute care facility, the right providers become partners in your health. Consider the following options as you build your personal healthcare network.

Montefiore Providers

When you choose Montefiore Tier 1 Network providers—our own doctors, hospitals and specialists—you’re getting high-quality care you can trust from the team that knows our patients and communities best.

• They’re held to the same standards of excellence that guide the care we deliver every day.
• You’ll pay the lowest copays and out-of-pocket costs available in our medical plans.
• Your providers can easily share information through MyChart, our electronic medical records, leading to better coordination of care.

Click here for a list of Montefiore Tier 1 Network providers. You can also log into your Anthem account, click “Find Care and Costs” and filter on Tier 1 providers.

Amazon One Medical

One Medical is a primary care practice that offers same- or next-day appointments and 24/7 virtual care for urgent issues, at no cost to you.

Amazon One Medical locations are in-network with most major insurance providers, including Anthem and 1199SEIU. Plus, if you are enrolled in a Montefiore Einstein medical plan, Amazon One Medical providers in Westchester County and Manhattan are part of the Montefiore Tier 1 Network, meaning you have access to convenient care at the lowest cost.

Visit the Amazon One Medical page to learn more and find details on how to claim your free membership, FAQs, helpful videos and more.

Anthem Network Providers

If you are enrolled in a Montefiore Einstein medical plan and choose not to use Montefiore providers, care from an Anthem Network provider will cost you less than out-of-network care.

Anthem defines the providers in their network and negotiates specific rates for care. Log into your Anthem account and click “Find Care and Costs” to find in-network care.

Montefiore Einstein Pharmacy makes it easier to fill your prescriptions in a way that works for you.

Advantages of using Montefiore Einstein Pharmacy include:

• Convenient options for home delivery or pickup at a Montefiore Einstein location near your work or home, at no extra cost.
• Potential prescription savings, including lower copays or even $0 cost for certain medications, depending on your plan.
• Dedicated one-on-one support with 24/7 access to a pharmacist.

Take a closer look at how Montefiore Einstein Pharmacy can be a smart choice by visiting the Prescription Drug Coverage page.

Additional ways to save on the cost of prescriptions:

• Generic drugs will cost you less than brand-name drugs. Talk to your provider or pharmacist to understand your options.
• If you have to get a brand-name drug, you will pay less if the drug is on the preferred list. Log into anthem.com to review the list. If a medication is not on the list, talk with your provider or pharmacies about high-quality, cost-effective options.

When it comes to your health benefits, you typically have three opportunities to enroll:

1. As a new hire
2. When you experience a qualifying life event (e.g., marriage or new child) and
3. During Annual Open Enrollment, held each fall

As you consider the medical plan that makes the most sense for you and your family, this is also a great time to look at other benefits that can help round out your coverage.

Save with a Tax-Advantaged Account

If you are eligible to participate in a Health Care Flexible Spending Account (FSA) or Health Savings Account (HSA) or, they can be great savings tools. You can set aside pre-tax earnings to pay for healthcare expenses, including out-of-pocket medical costs, medications and even dental and vision expenses. Visit Spending Accounts for more information.

Protect Yourself from High Costs

HealthyME offers supplemental insurance benefits, such as Accidental and Critical Illness Insurance, designed to pay a lump-sum amount when you experience an eligible event. Log in to the HealthyME Benefits Center to view the options available to you.

Benefits always come with some jargon. It’s important to speak the language to fully understand your benefits.

Carrier: The companies we partner with to provide benefits. For example, Anthem is our medical plan and prescription drug carrier.

To manage your annual costs:

• Contributions: The amount taken from your paychecks each pay period for the cost of coverage
• Annual deductible: The annual amount you pay out of pocket before the plan begins sharing in the cost of care
• Copay: A predefined dollar amount you pay when you receive care
• Coinsurance: A percentage of the total cost you pay when you receive care
• Out-of-pocket maximum: The most you will pay in a given year. Once you reach the maximum, the plan pays 100% of all eligible expenses
• Claim: Your providers submit claims to the carrier for any care you receive. Each claim is reviewed by the carrier to determine eligibility and cost share
• Explanation of Benefits (EOB): A document you’ll receive from the carrier summarizing how they processed a claim. It will detail the services received, the provider’s charges, the amount covered by the plan and what you owe. An EOB is not a bill. You should always review the EOBs you receive to confirm they match your expectations and contact the carrier with any questions

Understanding care options and requirements:

• In-network care or in-network provider: A doctor, hospital or other provider that has agreed to accept pre-negotiated amounts. Montefiore Einstein’s medical plan includes two networks:
  • Montefiore Tier 1 Network, made up of Montefiore Einstein providers and facilities as well as Amazon One Medical providers in Westchester County and Manhattan. These providers will always cost you less out of pocket for trusted, connected, world-class care; and
  • Anthem network, made up of providers and facilities Anthem has screened and negotiated with.
• Out-of-network care or out-of-network provider: A doctor, hospital or other provider that does not participate in either of the networks explained above. Services from these providers will either cost you more out of pocket or are not covered at all. Only the MonteCare PPO medical plan offers coverage for out-of-network care.
• Pre-admission certification/prior-authorization: Before you can receive certain types of care, like a hospital stay or some outpatient procedures, your medical plan may need to approve it in advance. Pre-admission certification or prior authorization confirms the service is medically necessary and covered under your plan. In most cases, in-network providers will request this approval for you, but it’s still your responsibility to ensure it has been obtained. Without it, your benefits may be reduced, or the service may not be covered.
  • To obtain a prior-authorization, please contact the Montefiore Care Management Team at 833-647-9355. This number is also located on the back of your Anthem insurance card.
• Preventive care: Services designed to prevent or detect illness before the condition develops or becomes more severe. In-network preventive care is covered at 100%, with age and frequency limits.

Prescription drug terms:

• Drug list: The list of preferred medications covered by the prescription drug plan. Visit anthem.com for the complete list. Important: Your drug list can change, so you should check it whenever you’re prescribed a new medication. Anthem will contact you if a drug you take is removed from the list.
• Generic drug (called Tier 1 by Anthem): An alternative form of a brand-name drug that has been shown to be equally effective while also being less costly. For example, Sertraline is the generic drug version of the brand-name drug Zoloft.
• Brand-name drug: A medication sold under a specific name or trademark that is protected by a patent. Brand-name drugs tend to be more expensive than generic drugs.
• Preferred brand (called Tier 2 by Anthem): Brand-name drugs included on the carrier’s drug list.
• Non-preferred brand (called Tier 3 by Anthem): Brand-name drugs that are not included on the carrier’s drug list. While they may be covered under the plan, they will cost more than preferred brand drugs.
• Specialty drugs (called Tier 4 by Anthem): A medication used to treat rate, chronic or complex condition (such as cancer, multiple sclerosis or rheumatoid arthritis). These drugs tend to be high-cost, high-complexity prescriptions. Note: Not all Anthem plans use a Tier 4 classification.