Get the Most from Your Coverage

Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. Use our Find a Provider tool to search through our directory of high quality providers.

As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call Superior if you need help finding an adult provider.

You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call Superior if you can’t get an appointment in a timely manner.

You should get high-quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered. Please review the Preferred Drug List (PDL). It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.

The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. Doctors and staff are not rewarded for saying no to care. All UM decisions are based on:

• If the service is medically necessary.
• If the service works well.
• If the service is right for you.

New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by Superior. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.

If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.

Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.

A full description of your rights and responsibilities and Notice of Privacy Practices (NOPP) can be found in your Member Handbook. You can also find Superior’s Provider Directories online by visiting Find a Provider. Contact Member Services to ask for a paper copy. Language assistance services, auxiliary aids and services, and other alternative formats are available to you free of charge. To obtain this, call the number on the back of your Superior ID card (TTY: 1-800-735-2989).