September 3, 2019

Contact Information MyPlan Information

Claims: Customer Service: MyPlan ID - PS00279533
Seven Corners - Attn: Claims Toll Free: 800-461-0430 MyPlan PIN - X66563H7
P.O. Box 3724 Fax: 317-818-2862
Carmel, IN 46082-3430 Email: info@[Link]
Fax: 317-575-6467 [Link]

NELIDA ESTRELLA COTRINA ROJAS

809 United Nations Plaza
New York, New York 10017

Welcome United States Department of State Exchange Participants!

Seven Corners is the administrator of the United States Department of State (USDOS) Accident and Sickness Program for
Exchanges (ASPE) Health Benefit Plan.
We are here to answer any questions you may have regarding your USDOS ASPE coverage and to process your healthcare claims.
Our overall goal is to provide member satisfaction through access to quality health care and excellent customer service, assisting
you in a better understanding of all of the elements of ASPE.
Provider Network - Your provider network in the US is First Health International and can be accessed online by going to
[Link]. It is a good idea to verify with the provider that they are still participating in the network. Using a PPO
network provider will save you money. To find a provider outside of the US - call customer service TOLL FREE at (800)461-0430
OR COLLECT FOR EXCHANGE PARTICIPANTS OUTSIDE OF THE US at (317)818-2867 for assistance in finding a provider
in your host country area and to coordinate scheduling of care. ASPE Health Benefit Plan has co-pays which are payable at the
time of service. $25 co-pay for office visits, $75 co-pay for ER, Hospitalizations and Urgent Care.
Pharmacy Network - Your prescription drug plan is through Catamaran. Network pharmacies may be viewed online by going to
[Link]. Note: for maintenance medication, you will need to use Catamaran's Direct Mail Service
Pharmacy. You may download a form at this website.
Pre-existing Condition Exclusion - USDOS ASPE does not provide benefits for any diagnosis that is considered a pre-existing
condition. A pre-existing condition is any condition which: a) had its origins prior to the Exchange Participant's effective date of
coverage; b) a Physician was consulted prior to the Exchange Participant's effective date of coverage, c) treatment or medication
was received prior to the Exchange Participant's effective date of coverage; or d) would have caused any prudent person to seek
medical advice or treatment, prior to the Exchange Participant's effective date of coverage.
Prenotification (Outside the US only) - Seven Corners must be contacted: a) to confirm coverage and benefits, b) as soon as
non-emergency hospitalization is recommended, c) within 48 hours of the first working day following an emergency admission,
d) when your physician recommends any surgery including outpatient, e) for emergency evacuation, repatriation and assistance
services, if in the United States, call 1 (800)461-0430, if outside the United States, call (317)818-2867 (collect).
Pre-certification (Inside the US only) - This healthcare plan requires precertification in the US for all inpatient hospital
admissions, skilled nursing, outpatient chemo and radiation therapy, outpatient surgeries and procedures, pregnancies, physical
or occupational therapy, dialysis, plasmaphoresis, MRI, PET scan, CT, home health and home infusion therapy.
MyPlan - MyPlan is a web site designed to allow secure access to your health benefit plan and claim
information. Please use the MyPlan ID and MyPlan PIN Number assigned above to activate your account. Additional information
regarding MyPlan is included in the enclosed materials. MyPlan web address: [Link]
Claims - Please send all claims to the claims address in the Contact Information section above.

IMPORTANT INFORMATION ABOUT YOUR BENEFITS

This healthcare plan requires precertification in the US for all inpatient hospital admissions, United States Department of State
skilled nursing, outpatient chemo and radiation therapy, outpatient surgeries and procedures Accident and Sickness Program for
pregnancies, physical or occupational therapy, dialysis, plasmaphoresis, MRI, PET scan,
CT, home health and home infusion therapy. You or your physician must call the Pre-certification Exchange Participants
phone number, (800)461-0430, to obtain preadmission approval at least one business day before
a planned hospitalization. Certification for emergency admissions or admissions due to an unexpected
illness or injury must be obtained within two business days following admission. Pre-certification
is not a guarantee of coverage. A $300 penalty will be applied if pre-certification is not obtained.
Insured: NELIDA ESTRELLA COTRINA ROJAS
For Pre-certification and benefit questions call (800)461-0430
24 hours a day 7 days a week (Except Holidays) ID#: PS00279533
To obtain a list of U.S. network providers call Seven Corners Assist or visit [Link]
SEND ALL CLAIMS TO: Seven Corners - Att: Claims CO-PAY: $25 co-pay for office visits Coverage Period: 08/04/2019 - 08/28/2020
P.O. Box 3724 $75 co-pay for ER,
Carmel, IN 46082-3724 Hospitalizations & Urgent Care.
CUSTOMER SERVICE: Toll free: 1-800-461-0430 Fax: 317-575-6467 Collect: 317-818-2867
Home Country: Peru
[Link]
To obtain a medication Present this card and your prescription at a Catamaran Network Pharmacy Program/Project: Fulbright Foreign Student
Attn: Pharmacist - enter the Policy Number and Group Number and transmit the claim through
your point-of-service system. Bin: 009117 Group Number: RX2537
Pharmacy Benefits questions call Catamaran toll free at 800-531-6351 24/7
Seven Corners provides administrative claims payment services only and does not assume financial
risk or obligation with respect to claims.

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