Member FAQs
Frequently Asked Questions
HMO
EPO, PPO, POS, High Deductible PPO
CDPHN Self-Insured Plans
Select Plan (Medicaid) and Family Health Plus
Child Health Plus
Individual Medicare
Prescriptions
Specialty Pharmacy
HMO
What should I do if I have an emergency when I’m out of the area?
A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.
If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment. See Out-of-Area coverage for details.
If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.
How do I change my primary care physician (PCP) or OB/GYN?
You can change your PCP or OB/GYN through Online Health™ using your member ID and password. If you need help choosing a physician, please contact the CDPHP Member Services Department. You also can access information about our participating providers at Find-A-Doc. Please contact the provider you are selecting to ensure that he/she is accepting new patients before you notify CDPHP of the change. You must register your choice of a new provider with CDPHP within five days of your appointment. Tip: If you have a referral/authorization or prescriptions from your former physician, please have these rewritten by your new doctor.
How do I submit a claim?
If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:
- Provider’s name, address, telephone number, and tax ID number
- Date of service
- Name of each procedure/procedure code, including the name of any drugs
- Charge for each procedure
- Diagnosis
- Receipt for any payment made
- Member’s name and ID number
Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.
How do I submit a foreign claim?
If you received medical treatment while traveling outside of the U.S., you will need to submit an itemized receipt to CDPHP for processing to the address above. The itemized receipt must include the above information in order to be considered for payment. CDPHP will have the foreign currency converted into U.S. dollars. If you have any concerns or questions, contact the CDPHP member services department.
Can I order my prescription drugs by mail?
Yes. The CDPHP prescription mail service benefit is available to members who have a prescription drug rider and who take maintenance medication.
EPO, PPO, POS, High Deductible PPO
What should I do if I have an emergency when I’m out of the area?
A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.
If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment. See Out-of-Area coverage for details.
If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.
How do I access my out-of-network benefits?
Members of the EPO do not have coverage outside the CDPHP network. If you have the PPO, POS, or High Deductible PPO, you have coverage for care from non-participating providers but you should understand that your costs will be higher than seeking care within the network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.
Do I have to choose a PCP to direct my care?
Members of the POS need to designate a PCP. If you have the EPO, PPO, or High Deductible PPO, you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.
How do I submit a claim?
If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:
- Provider’s name, address, telephone number, and tax ID number
- Date of service
- Name of each procedure/procedure code, including the name of any drugs
- Charge for each procedure
- Diagnosis
- Receipt for any payment made
- Member’s name and ID number
Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.
How do I submit a foreign claim?
If you received medical treatment while traveling outside of the U.S., you will need to submit an itemized receipt to CDPHP for processing to the address above. The itemized receipt must include the above information in order to be considered for payment. CDPHP will have the foreign currency converted into U.S. dollars. If you have any concerns or questions, contact the CDPHP member services department.
Can I order my prescription drugs by mail?
Yes. The CDPHP prescription mail service benefit is available to members who have a prescription drug rider and who take maintenance medication.
CDPHN Self-Insured Plans
What should I do if I have an emergency when I’m out of the area?
A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.
If you have an emergency outside of the CDPHN service area, go to the nearest hospital emergency room. Call CDPHN within 48 hours or as soon as possible; CDPHN will
cover the hospital emergency room bill in full — minus your applicable copayment, coinsurance, and deductible.
If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHN Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.
Refer to the benefit materials supplied by your employer for more specific information.
How do I change my primary care physician (PCP) or OB/GYN?
If employer group plan requires that you register your choice of a PCP and OB/GYN, you can modify these selections online at Online Health™ after logging in with your ID number and password. If you need help choosing a physician, please contact the CDPHN Member Services Department at the number listed on your ID card. You also can access information about our participating providers at Find-A-Doc. Please contact the provider you are selecting to ensure that he/she is accepting new patients before you notify CDPHN of the change. To help CDPHN coordinate your coverage, please register your choice of a new provider with us within five days of your appointment. Tip: If you have a referral/authorization or prescriptions from your former physician, please have these rewritten by your new doctor.
How do I submit a claim?
If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:
- Provider’s name, address, telephone number, and tax ID number
- Date of service
- Name of each procedure/procedure code, including the name of any drugs
- Charge for each procedure
- Diagnosis
- Receipt for any payment made
- Member’s name and ID number
Please send claim to: Capital District Physicians’ Healthcare Network, Inc., P.O. Box 66602, Albany, NY 12206-6602.
How do I submit a foreign claim?
Refer to your benefit materials to confirm that you have coverage while traveling out the country. Generally, if you receive medical treatment while traveling outside of the U.S., you will need to submit an itemized receipt to CDPHN for processing to the address above. The itemized receipt must include the above information in order to be considered for payment. CDPHN will have the foreign currency converted into U.S. dollars. If you have any concerns or questions, contact the CDPHP member services department.
Can I order my prescription drugs by mail?
If your employer offers drug coverage that is administered by CDPHN, a prescription mail service benefit is available to you to fill prescriptions for maintenance medications.
Select Plan (Medicaid)
Do I have to choose a primary care physician (PCP) when I join Select Plan or Family Health Plus?
Yes. If you do not select a PCP you will not receive your ID card. Select a doctor whose office is nearby or easy to get to. If you don’t choose a PCP, CDPHP will choose one for you. Your PCP’s name will be shown on your ID card. You can access information about participating providers through Find-A-Doc. Log into Online Health™ to change your PCP or contact the CDPHP Member Services Department at 1-800-388-2994.
How do I choose a primary care physician?
You can access information about participating providers at Find-A-Doc. Log into Online Health™ to change your PCP or contact the CDPHP Member Services Department at 1-800-388-2994.
What should I do if I move?
CDPHP needs to know if you have changed your address. If you are planning on moving, please contact your local Department of Social Services and CDPHP as soon as possible in order to keep your enrollment records up to date. You can also update your address and phone number in Online Health™.
Is transportation available to take me to the doctor or dentist?
Select Plan members in Albany, Columbia, Schoharie, and Rensselaer counties are provided with non-emergency transportation for medical and dental appointments. To use this service, contact your local Department of Social Services.
Child Health Plus
When are my payments due?
Refer to your contract for payment due dates and grace periods. Premium payments for this contract are due in advance. Monthly payments are due on the first day of the month prior to the coverage period. To ensure continuous coverage, premium payments must be received within the 30-day grace period allowed in your contract to prevent termination for non-payment of premium.
Do I have to send my coupon with my payment?
Yes. Please put the member’s ID number and division number on all checks or money orders, and mail to CDPHP, P.O. Box 66605, Albany, NY 12206-6605.
Is my child’s medicine covered with Child Health Plus?
Yes. The Child Health Plus contract provides for medically necessary prescription and non-prescription (over-the-counter) medications. A participating provider must authorize all medications. Please contact Caremark® Customer Care at 1-888-292-6330 if you have questions about your prescription drug coverage.
Individual Medicare Plans
Can I get extra medicine if I am going to be on vacation?
Yes. Caremark® Customer Care will provide up to a 90-day vacation override for Medicare members who have Medicare Part D drug coverage and request an “out-of-area” vacation supply.
The prescription must be obtained through a Caremark® participating retail pharmacy. Be sure that you have enough refills on your prescriptions in order to process the vacation request.
You will be responsible for a copay for each 30-day supply. These prescriptions are subject to the rules in the Medicare Evidence of Coverage. Contact Caremark® Customer Care at 1-866-289-2319. A representative will handle your request and any questions that you may have.
Do I need to send in my premium coupon?
Yes. Medicare members should submit their premium coupons with payments for the month. Remember to write your ID number on your check in order to ensure proper posting. Mail it to CDPHP, P.O. Box 66605, Albany, NY 12206-6605.
You can also have your health insurance premiums electronically deducted from your checking account. For more information, download an Authorization Agreement for Electronic Premium Deductions or contact the CDPHP Medicare Member Services Department.
How do I use the eyeglasses allowance?
There are two ways to receive your $80 allowance for eyeglasses:
a) The vendor where you purchase your eyeglasses or contact lenses can send their claim directly to CDPHP. CDPHP will apply the $80 allowance toward that claim. You would be responsible for the balance.
b) You can pay the eyeglass vendor in full for your glasses or contact lenses when you receive them. At that time, you must obtain an itemized receipt from the vendor, and submit that receipt to CDPHP. We will then send the $80 allowance check directly to you.
Prescriptions
How can I find out more about my prescription drug benefit?
Drug coverage varies depending on your drug rider. To find out more about your prescription drug benefit, including your prescription copayments, the formulary, maximum drug allowances, and other limitations, please review your health plan materials, check with your health benefits administrator, log onto Caremark.com, or call Caremark® Customer Care.
What is a formulary?
A formulary is a select list of brand name and generic drugs that offer a clinical and/or economic advantage when compared to other similar drugs available to treat the same medical conditions. Health maintenance organizations and health insurance companies commonly use formularies to help ensure safe, cost-effective health care. All drugs on the CDPHP formulary have been reviewed by the CDPHP Pharmacy and Therapeutics Committee. To search for drugs listed on the CDPHP formulary, go to Drug Coverage & Pricing.
Are over-the-counter (OTC) drugs covered?
OTC drugs are generally not covered by CDPHP. Government programs, including Medicaid, Child Health Plus, and Family Health Plus programs, may cover certain over-the-counter drugs.
How can I get reimbursed for prescriptions I paid for out-of-pocket?
If you've paid out-of-pocket for prescriptions, you may send your itemized pharmacy receipts with a completed Prescription Claim Form to Caremark® for payment consideration. Prescriptions that were purchased outside the United States require a Foreign Claim Form. Medicare Part D Members should send their itemized pharmacy receipts with the Prescription Claim Form for Medicare with Part D. Follow directions on claim forms and allow 21 days for claims processing.
Under certain circumstances, your pharmacy may be able to reimburse you directly. For more information on direct claim reimbursement, please call Caremark® Customer Care.
Who decides which drugs are covered by CDPHP?
CDPHP has a Pharmacy and Therapeutics (P&T) Committee consisting of participating physicians and practicing pharmacists that determines how CDPHP will cover drugs. The P&T committee meets five times a year to evaluate new drugs and drug classes for their safety, efficacy, and overall therapeutic and cost value.
Are drugs that are new to the market covered by CDPHP?
All new to market drugs require a prior authorization until reviewed by the P&T committee. If your physician prescribes a new to market drug that hasn’t yet been reviewed, it will be considered for coverage only after a medical exception form is submitted to the CDPHP pharmacy department. The medical exception request process must be followed and the request approved before filling the prescription.
Why do some drugs require prior authorization?
Prior authorization is a process to ensure the appropriate use of certain drugs according to current CDPHP policies. The process must be followed and the request approved before filling the prescription.
Why do certain drugs have quantity limits?
Quantity limitations are in place to ensure that drugs are used appropriately due to quality and/or clinical considerations. Quantities in excess of the assigned limits require prior authorization. The process must be followed and the request approved before filling the prescription.
How does the Step Therapy program work?
The Step Therapy program is another form of prior authorization whereby certain drugs are not covered unless members have tried one or more "prerequisite therapy" medication(s) first. If it is medically necessary for a member to use a step-therapy medication as initial therapy the practitioner can submit a medical exception. The process must be followed and the request approved before filling the prescription.
What is the Dose Optimization program?
Dose Optimization is a program to support appropriate and cost-effective therapy by recommending a higher once-daily dose of a product when members are taking multiple daily doses of a lower strength. For example, a member may be taking two 20 mg tablets of a drug per day when only one 40 mg tablet per day could be used. If a practitioner determines that multiple daily doses are necessary a medical exception form can be submitted for consideration.
What if my physician decides I need a drug that is not covered by my drug rider?
Coverage for formulary-excluded drugs will be considered only when your physician has documented that the drug is medically necessary by completing the medical exception form. The medical exception process must be followed and the request approved before filling the prescription.
What if I pay cash and submit a receipt for reimbursement for a drug that requires medical exception or a prior authorization?
Drugs that are excluded from the formulary or require a prior authorization must be approved in advance by having your physician contact the CDPHP Pharmacy Services Department at (518) 641-3784. You must receive notification of the approval before filling the prescription in order to be eligible for claim reimbursement.
How can I find a pharmacy in my area that participates with CDPHP?
To a find a CDPHP-participating pharmacy in your area, go to the Pharmacy Locator link. If you’re having a problem locating a pharmacy in your area, please call Caremark® Customer Care.
I am going on vacation and I will need to refill my prescription while I am away. What are my options?
Use the CDPHP Mail Service Option if it’s included in your benefit plan, or take a prescription with you and fill it at any Caremark® participating pharmacy. To find a participating pharmacy, please go to Pharmacy Locator or call Caremark® Customer Care.
Unless your drug rider has placed a limitation on this benefit, CDPHP allows one 30-day vacation supply per drug per calendar year. Additional requests will be reviewed on a case-by-case basis. All requests must be called into Caremark® Customer Care as soon as possible. You must have valid prescriptions for refills or new prescriptions.
Does CDPHP have a mail order program?
Yes. Your health benefit plan may include a Mail Service Option. It is currently not available to Child Health Plus, Select Plan, Family Health Plus, Healthy NY and Non Group members. To confirm that you have this option, please review your member materials, check with your health benefits administrator, or contact Caremark® Customer Care.
How do I use the mail service option?
Caremark provides the mail order form that needs to be sent in with each order. Complete the Mail Order Form. Simply follow the instructions in the Prescriptions By Mail Overview Brochure to complete the form and to place your order. Medicare members with Part D should review the Prescriptions By Mail Overview Brochure for Medicare Part D
Specialty Pharmacy
What are specialty medications and who provides them?
Specialty medications target and treat specific chronic or genetic conditions, and are available in oral, injectable, and infused forms. Caremark Specialty Pharmacy Services is a leading provider of specialty pharmaceuticals for individuals suffering from complex chronic or genetic conditions. For a current list of specialty medications provided by Caremark Specialty Pharmacy Services, click here.
What does Caremark Specialty Pharmacy Services provide?
Along with the convenient delivery of your medication, Caremark provides a broad array of services that include side-effect counseling, condition-specific materials, refill reminder calls, and access to health care professionals for emergency consultation, 24 hours a day, seven days a week. Caremark Specialty Pharmacy Services will determine your coverage and obtain all the necessary authorizations from CDPHP and your doctor.
How do I get started?
Getting started with Caremark Specialty Pharmacy Services is easy. You have three different options for contacting them:
- Call CaremarkConnect® at 1-800-237-2767. A representative will collect all of your information and work with your doctor to obtain a new prescription.
- Your doctor can fax a completed enrollment form to 1-800-323-2445. A CaremarkConnect representative will then contact you to obtain any information needed to complete the ordering process.
- Or you can visit the Specialty Pharmacy Services section at Caremark.com and enroll online. Once you've enrolled, a CaremarkConnect representative will contact you and your doctor to complete the ordering process.
How will my payment obligation be affected?
Your copayments and coinsurances for a 30-day supply will not change when you switch to Caremark from either a retail pharmacy or any other specialty pharmacy. You can either pay at the time of order or Caremark Specialty Pharmacy Services can bill you after your prescription is dispensed. If you choose to pay up front, simply provide a credit card number or checking account information (i.e., your account number, bank routing number, and specific check number) when you call to place your order or refill.