Your Guide to

Health Care Coverage
Description of the Corporation

Created in 1993, the Corporation for National 

and Community Service (CNCS) engages more 

than 2 million Americans annually in improving 

communities through service. CNCS supports 

service at national, state, and local levels 

through:

* Senior Corps, the network of programs that 

helps Americans age 55 and older use their 

skills and experience in service opportunities 

that address the needs of their communities. 

Senior Corps includes the Retired and 

Senior Volunteer Program (RSVP), Foster 

Grandparent Program, and Senior Companion 

Program;

* AmeriCorps, whose members serve with local 

and national organizations to meet community 

needs while earning education awards to help 

finance college or training; and

* Learn and Serve America, which helps link 

community service and learning objectives 

for youth from kindergarten through 

college as well as youth in community-based 

organizations.

Upon request, this material will be made available in 

alternative formats for people with disabilities.

CNCS is pleased to welcome you as an 

AmeriCorps*VISTA or AmeriCorps*NCCC 

member. As a member you are entitled to an 

exclusive health care plan designed by CNCS and 

administered by Seven Corners, Inc. This plan 

should not be construed as an insurance policy.

This guide describes the health care benefits 

you are entitled to while serving as an 

AmeriCorps*VISTA or AmeriCorps*NCCC

member. It also explains how payments are made 

for covered health care expenses. Throughout 

this guide, the covered services you are entitled 

to are called “your benefits.” This guide is an 

overview of your health care program and 

reading it will familiarize you with the program’s 

main provisions.

The AmeriCorps health care plan provides you 

with 24 hour health care coverage automatically 

upon your entry into training or service.

Your health care benefits will terminate automatically on 

the date your service ends.

If you re-enter service with AmeriCorps*VISTA 

or AmeriCorps*NCCC within 180 days of the 

termination of your previous service, those 

medical conditions covered during your previous 

term of service will be covered during the new 

term of service. However, illnesses or injuries 

incurred during the gap in service will not be 

covered and will be considered to be pre-existing 

conditions.

This guide is an 

overview of your health care program 

and reading it will familiarize you 

with the program’s main provisions.

WELCOME
QUICK

REFERENCE

GUIDE

Use this Quick Reference Guide for easy access to frequently asked questions regarding your AmeriCorps 

health care benefits.

Select a provider from the 

PPO network

Search for a provider online at www.americorps.sevencorners.com or call 

customer service at 1.866.699.4186. Also, verify with provider they are a 

participating member of the network prior to receiving services.

Replace your ID card Call Customer Service toll free at 1.866.699.4186, or request a card on-line 

from our web site at www.americorps.sevencorners.com.

Check on eligibility

or benefits

Call Customer Service toll free at 1.866.699.4186, or visit us on-line at 

www.americorps.sevencorners.com.

Request a claim form Call Customer Service toll free at 1.866.699.4186, or download a form 

from our web site at www.americorps.sevencorners.com.

Schedule provider visits Call your provider.

Seek precertification Call provider to coordinate. If you are reporting this yourself, call Customer Service toll free at 1.866.699.4186.

Be admitted to

a hospital

Have provider initiate precertification for all non-emergency admissions by 

calling 1.866.699.4186.

Receive emergency care

Seek care at nearest hospital / source of medical care. If admitted to 

hospital, call Customer Service toll free at 1.866.699.4186, within two 

business days.

Submit claims Have network provider submit claims for services or see page 11 of this 

guide for instructions.

Inquire about bills you 

receive from a provider

or facility

Call Customer Service toll free at 1.866.699.4186, or e-mail Customer

Service via our website at www.americorps.sevencorners.com

Convert coverage

upon termination

Call Customer Service toll free at 1.866.699.4186, visit us on-line at 

www.americorps.sevencorners.com, or call Celtic Life Insurance Company 

at 1.800.365.2365.
CUSTOMER SERVICE 1

Identification Card 1

COVERED SERVICES 2

Emergency Services 2

Hospital Inpatient Services 2

Lifetime Maximum 2

Maternity Care 2

Mental Health Services 3

Professional Services 3

Pre-existing Conditions 3

Prescription Drugs 3

Preventive Care 3

Surgical Care 3

Other Services 3

GENERAL INFORMATION 5

Quality Service 5

Copayment 5

Preferred Provider Organization (PPO) 5

HOSPITAL PRECERTIFICATION 6

PRESCRIPTION DRUG PROGRAM 7

How to Fill a Prescription 7

How to Find a Participating Pharmacy 7

What You Should Do if Your Pharmacy is not Part of the PharmaCare Network 7

List of National Pharmacies 7

What About Generics 9

Mail Service Pharmacy 9

Prescription Drug Program Exclusions 9

EXCLUSIONS TO COVERED SERVICES 10

HOW TO SUBMIT A CLAIM 11

Coordination of Benefits 11

How to Submit Your Claims 12

APPEAL PROCEDURES 13

How to Appeal a Precertification Decision 13

How to Appeal a Claim Decision 13

SUBROGATION 13

CONVERSION 13

GLOSSARY OF TERMS USED IN THIS GUIDE 14

TABLE OF 

CONTENTS
CUSTOMER SERVICE

Providing quality customer service is important to AmeriCorps. 

For that reason, we offer access to customer service through 

our toll-free customer service line at 1.866.699.4186 and via the 

Internet at www.americorps.sevencorners.com. Now, you can 

get answers to your health care questions at any time of the day 

or night. 

USING THE AMERICORPS E-SERVICE

It’s easy to access information about your health plan through 

www.americorps.sevencorners.com. Just log in for access to:

❖ Customer Service Representatives

❖ Claim status

❖ Benefit Plan Guidelines

❖ Downloadable forms

❖ Eligibility information

❖ Printable ID cards

❖ Pharmacy Network

❖ Provider Network

When viewing areas where personal health information is present, a username and password are required. Your username, 

password and identification card will be issued to you within 24 

hours of receipt of eligibility information.

CUSTOMER

SERVICE 1

IDENTIFICATION CARD

As an AmeriCorps member you will receive an identification 

card to be used as proof of health care coverage when you 

need medical services. Simply show your identification card 

to the hospital, physician or provider at the time of service. 

You should carry your identification card with you at all times 

in case you need emergency treatment. The identification 

card also serves as a prescription drug card for use when filling prescriptions at all PharmaCare network pharmacies. 

The back of your identification card contains important 

information regarding procedures and the address used to file 

claims.

Lost or misplaced cards can be replaced by calling Customer 

Service at 1.866.699.4186. A copy of your card can be 

emailed to you and a new card will be mailed within 24 hours.

MyPlan - Login

Username

Password

Enter Cancel

Correspondence Mailing Address:

AmeriCorps

Attn: Customer Service

P.O. Box 3430

Carmel, IN 46082-3430
Emergency SERVICES

The plan covers emergency outpatient services for injuries 

resulting from an accident, including an automobile accident and 

emergency illness. A $25 copay applies to each emergency room 

visit. The copay is waived for AmeriCorps*VISTA members 

only if you are admitted to the hospital through the emergency 

room. It is waived for AmeriCorps*NCCC members for all 

emergency room visits.

HOSPITAL INPATIENT SERVICES

If you are confined to a hospital, the health plan will pay 

hospital charges for the services listed below which are not 

related to pre-existing conditions. If you are hospitalized 

prior to your service termination date and the hospitalization 

continues past the termination date, medical expenses for the 

duration of the hospitalization will not be covered under this 

health plan. 

NOTE: When you leave the AmeriCorps program you should 

always consider Conversion Coverage. (see page 13.)

ROOM AND BOARD

The AmeriCorps health care plan provides care up to 21 

days per benefit year and no more than 60 days per lifetime 

of service. Room and board, general nursing care, meals and 

dietary services provided by the hospital are covered for a semiprivate room or ward accommodations. If a private room is 

medically necessary, the plan will cover the cost.

INPATIENT HOSPITAL SERVICES

Inpatient hospital services include charges incurred for 

operating, recovery, delivery, labor, intensive care, coronary 

care and cystoscopic rooms. An annual maximum of 21 days 

of inpatient room and board can be used for mental health 

treatment and for alcohol or substance abuse for detoxification 

in a hospital or licensed inhospital detoxification facility. 

NOTE: 

* Covered services are subject to the pre-existing condition 

clause.

* Outpatient treatment of alcohol or substance abuse is not a 

covered service. (see page 10.)

PRECERTIFICATION

All inpatient hospital stays, including detoxification facilities, 

must be precertified. If a network hospital is in your area, you 

should use that facility in order to avoid the potential risk of 

being billed for charges in excess of usual and customary fee 

schedules. (See page 5 for information about the preferred 

provider organization network.)

If your provider recommends hospitalization, you must call 

1.866.699.4186 for precertification. (See page 6 for instructions 

on how to precertify a hospital stay.) A $300 penalty will be 

applied if precertification is not obtained prior to hospitalization. 

The member is responsible for paying all applicable penalties. 

Note: Precertification is not a guarantee of payment , 

but a process to document medical necessity.

LIFETIME MAXIMUM

You will realize unlimited medical benefits for most covered 

services. (See Pre-existing Conditions on page 3 and Excluded 

Benefits on page 10.)

MATERNITY CARE

AmeriCorps provides maternity benefits for members who 

are in active service prior to becoming pregnant and through 

delivery of the child. A pre-existing condition limitation applies 

to any member who is pregnant prior to entering service.

Covered maternity services include prenatal care, delivery of the 

child, hospitalization and treatment of the mother relating to the 

delivery of the child including any complications affecting the 

mother. Complications affecting the infant are not covered. For 

newborn coverage, see Nursery Care under Other Services.

Benefits will be paid for all covered services provided by a 

certified nurse midwife who is a licensed registered nurse and 

certified as a nurse midwife by the American College of Nurse 

Midwives or meets other requirements as mandated by law. 

(Continued on next page.)

COVERED SERVICES

(Subject to the pre-existing 

condition limitation)

2

Checking the list of covered services prior to

having services performed saves you money.
MATERNITY CARE (continued)

A member who enters service or a member who becomes 

pregnant during service may continue their service provided they 

can continue to perform full-time duties. If the member wishes 

to remain in service beyond the delivery date, the member must 

have sufficient leave available for recuperation after giving birth 

(additional information on pregnancy and your services can be 

found in the appropriate AmeriCorps member handbook). 

MENTAL HEALTH SERVICES

Inpatient care: The AmeriCorps health plan covers mental 

health care for inpatient hospital services subject to the preexisting condition clause. (See Inpatient Hospital Services on 

page 2.)

Outpatient care: When outpatient mental health care is provided 

by a physician, a psychiatrist, a licensed clinical psychologist or a 

master of social work, the following benefits apply:

1. Three outpatient mental health visits are covered per 

benefit year that are not subject to limitations on preexisting conditions.

2. Any additional outpatient mental health visits are subject 

to the pre-existing condition clause.

PROFESSIONAL SERVICES

Professional services include services provided by a physician 

for the treatment of a medical condition in a hospital, physician’s 

office or your home. The AmeriCorps health care plan will pay 

up to the usual, customary and reasonable charges for these 

types of services. 

Consultation services are covered if a second surgical opinion is 

needed in order to confirm your diagnosis or treatment. 

Approved providers of service include Doctor of Medicine 

(MD), Doctor of Osteopathy (DO), Doctor of Dental Surgeries 

(DDS or DMD), Psychologist (PhD) and any other provider 

licensed in the state where services are provided. Special nursing 

services by actively practicing nurse practitioners, registered 

nurses, licensed practical nurses and licensed vocational nurses, 

as prescribed by a physician, are also included.

PRE-EXISTING CONDITIONS

AmeriCorps does not provide benefits for any diagnosis that is 

considered a pre-existing condition. A pre-existing condition is 

any condition or illness for which medical treatment was given,

or a diagnosis was made, on or before the effective date of

coverage. 

Exception: All members who are medically terminated and 

reinstated at a later date will have the condition for which they 

were medically terminated covered by the health plan.

If a claim is submitted that appears to be a pre-existing illness 

or condition, medical records will be required to make a 

determination.

PRESCRIPTION DRUGS

PharmaCare prescription drugs must be obtained from a 

participating pharmacy. (See page 7 for more information.)

PREVENTIVE CARE

The AmeriCorps health care plan pays for only the following

preventive / routine care services for female members:

1. One GYN health visit per service year that includes one

pelvic examination, Pap smear, breast examination and lab

work related to GYN health when performed at the time of

the annual GYN health visit.

2. Contraceptive management.

3. One mammogram for women over 40 is covered per service

year. All other routine mammograms are not included as part

of these services.

For males over 50, one prostate examination, including a PSA, is

covered by the plan per service year.

SURGICAL CARE

AmeriCorps pays for surgical expenses whether on an inpatient 

or outpatient basis. Surgical expenses include usual pre-operative 

and post-operative care for treatment of a disease, injury 

or ailment; cutting or incision; and/or suturing of wounds; 

treatment of fractures and dislocated bones; and endoscopic 

procedures where a tube is inserted to examine internal organs 

or for the treatment of fractured and dislocated bones. 

OTHER SERVICES

Anesthesia - General anesthesia,spinal anesthesia, andepidurals 

will be covered when administered by an anesthesiologist. Other 

anesthesia, including conscious sedation, may be administered 

by the attending physician, dentist or registered nurse as dictated 

by hospital or facility policy.

COVERED SERVICES

(Subject to the pre-existing 

condition limitation) 3
OTHER SERVICES (continued)

Ambulance - Professional ambulance service to the nearest 

hospital where the member can be treated or to another hospital 

in the area if necessary treatment is not available at the nearest 

hospital is covered. Ambulance service from the hospital to the 

member’s home, only if medically necessary, is also covered. 

Artificial Limbs or Eyes - Prosthetic appliances and 

orthopedic braces for disabilities arising during service, and the 

repair of such appliances and their replacement when medically 

necessary.

Birth Control - Oral contraceptives, diaphragms, IUDs and 

contraceptive injections when prescribed by a medical doctor.

Blood - Blood, blood plasma or blood expanders when not 

donated or replaced.

Dental - Dental services necessary for the performance of a 

surgical service to correct non-chewing accidental injuries of 

the jaw, cheeks, lips, tongue, roof and floor of the mouth as well 

as x-rays, teeth, supporting bone and tissue that occur while the 

member is covered under this contract including x-rays as the 

result of an accidental bodily injury.

Emergency dental services covering care which must be 

provided immediately for the relief of pain and the correction 

of the disorder causing the pain. Emergency services covered 

may include treatment of abscesses, root canals and extractions, 

but will not include cleaning, crowns, dentures, routine fillings 

or the routine removal of wisdom teeth. 

Diabetic Supplies - Insulin, lancets, alcohol swabs, 

glucometers, test strips, disposable needles and syringes only.

Equipment - Includes casts, splints, trusses, braces, crutches 

or surgical dressings.

Equipment Rental (DME) - Includes rental or purchase 

(whichever is less) of durable medical equipment deemed 

necessary for therapeutic use including crutches, wheel chair, 

hospital bed and oxygen and rental of equipment for its 

administration.

Note: Physician’s order required to be considered for 

payment.

Facility Expenses - Charges associated with operating, 

recovery, delivery, labor, intensive care, coronary care and 

cystoscopic rooms.

Hearing - Repair of hearing aid when device is broken or lost 

in the line of duty.

Hemodialysis - Services provided by a freestanding 

hemodialysis center (except in the case of Chronic Renal Failure 

and End Stage Renal Disease).

Immunizations - Those immunizations recommended 

by the United States Center for Disease Control. All other 

immunizations required for travel outside of the United States 

are not covered. (see Page 10.)

Laboratory Tests and X-Rays - Services are covered 

if recommended or performed by a licensed provider for 

diagnostic purposes due to symptoms, illness or injury. 

Ostomy Supplies

Nursery Care - Routine care for newborn while mother is 

hospitalized for covered maternity care.

Radiation Therapy - Radiation and chemotherapy including 

treatment of disease by chemical, biological antineoplastic 

agents, x-rays, radium or radioactive isotopes.

Therapy

Occupational Therapy - Services covered when 

provided by a physician or by a licensed occupational 

therapist when prescribed by a physician.

Phototherapy - Services covered when provided by 

a physician or by a licensed phototherapy nurse when 

prescribed by a physician. Note: tanning / tanning salons 

are not covered.

Physical Therapy - Services covered when provided 

by a physician or by a licensed physical therapist when 

prescribed by a physician.

Speech Therapy - Services covered when provided by a 

physician or by a licensed speech therapist when prescribed 

by a physician.

Vision - Charges for an eye examination, replacement of 

eyeglasses or contact lenses lost or damaged in the line of duty 

are subject to the following schedule:

Replacement/repair of frames and lenses (combined) $50

Eye examination for eyeglass replacement $25

Replacement of contact lenses $50

Eye examination for contact lens or lens replacement $25

NOTE: Services related to the treatment of eye disease or eye injury 

are covered, subject to the pre-existing condition limitation.

COVERED SERVICES

(Subject to the pre-existing 

condition limitation) 4
QUALITY SERVICE

The AmeriCorps health care plan is administered by Seven 

Corners, Inc. As a specialist in claims and billing administration, 

you can be assured of quick personalized service. Customer 

service representatives are available to answer any questions 

you may have regarding the PPO network, claim payments 

or covered benefits by calling Customer Service toll free at 

1.866.699.4186 or visit us on-line at:

www.americorps.sevencorners.com.

COPAYMENT

You will be responsible for a $5.00 copay for each medical office 

visit. This charge will be expected to be paid at the time of your 

visit and will be deducted from the total cost of the services. No 

copay will be charged for inpatient services.

Effective 8/1/2005 AmeriCorps*NCCC members will be 

responsible for a $5.00 copay for each prescription drug purchased.

PREFERRED PROVIDER 

ORGANIZATION (PPO)

Your health plan contains a Preferred Provider Organization 

(PPO) benefit. A PPO is a network of physicians, hospitals and 

clinics who have entered into an agreement with AmeriCorps to 

accept discounted fees for services they provide to AmeriCorps 

members. 

Using a PPO provider saves you money because AmeriCorps 

will pay 100% of the covered charges (or up to the policy limit). 

In most states, payment will not be required at the time of 

services (except for the co-pay amount).

Failure to use an available PPO provider in a network area 

will result in your being responsible for charges over the 

usual and customary amount. This means you will be 

responsible for any costs not paid by the health care plan 

and providers may require payment at the time of service. 

AmeriCorps*NCCC members on spike are exempt from 

this requirement.

AmeriCorps uses the ChoiceCare national PPO network. Claims 

for services provided by a PPO provider should be mailed 

directly to Seven Corners at the address on the back of your 

identification card. 

You may search for a network provider from the provider 

directory on our website at www.americorps.sevencorners.com 

or call customer service toll free at 1.866.699.4186 for assistance 

in locating a provider.

If your residence is over 35 miles from the nearest PPO provider, 

you are exempt from the PPO guideline. You are free to see any 

provider of your choice. AmeriCorps*NCCC members on spike 

are encouraged to use the PPO network but are not required to 

use it. 

GENERAL

INFORMATION 5

Using a PPO provider saves you money.
UTILIZATION MANAGEMENT

The AmeriCorps health plan includes a utilization management 

program to review the use of your health care benefits. This 

program applies to members who receive services within the 

United States, Puerto Rico, the Virgin Islands and territories 

of the United States. The program ensures that the care you 

receive is medically necessary, cost effective and the type of 

care you need is appropriately provided.

The utilization management program is administered by 

registered nurses and board certified physicians. 

The following services are provided through the utilization 

management program:

* Preadmission and admission review of all hospital 

admissions, including inpatient psychiatric and obstetrical 

admissions.

* Continued stay review of all hospitalizations.

* Individual case management of potentially catastrophic 

and costly cases. 

How the Precertification

Program Works

If your physician recommends that you be hospitalized, 

you must call 1.866.699.4186 for preadmission certification.

All hospitalizations require preadmission and admission review, 

including obstetrical and psychiatric admissions. Preadmission 

approval must be obtained at least one business day before 

a planned hospitalization, and within two business days 

after admission date for an emergency admission or an 

admission due to an unexpected illness or injury.

To obtain the necessary precertification approval, call toll free 

1.866.699.4186. Preadmission certification hours are 9:00 am 

to 5:00 pm EST Monday through Friday. After service hours, 

you may leave a message that will be answered during the next 

business day. 

Be prepared to give the following information:

1. Member name and identification number

2. Provider name and telephone number

3. Hospital name and date of planned admission

4. Type of procedure to be performed

The preadmission certification process may be initiated by you, 

a family member, your provider or a hospital representative. 

Once the preadmission certification has taken place, you, your 

provider and the hospital will receive written notice within 24 

hours of the precertification decision and the approved number 

of hospital days. Precertification approval does not mean 

coverage approval. Coverage approval is based on the terms 

and conditions described in this guide.

If your hospital admission has been precertified, AmeriCorps 

will review your admission and determine if additional hospital 

days are medically necessary. If an extension cannot be 

approved, a physician advisor will review your case, discuss 

your admission with your provider and render a decision.

Share the preadmission certification information from this 

guide with a family member or other responsible person who 

could contact AmeriCorps and arrange for your medical care in 

the event you are unable to do so yourself.

HOSPITAL

PRECERTIFICATION 6

YOU SHOULD KNOW...

Failure to consult and obtain precertification 

of your inpatient hospital admission will result in a $300 reduction in benefits. You will 

be responsible for paying this amount.
The AmeriCorps health care plan provides a prescription 

drug program to be used in combination with your health 

care benefits. PharmaCare is your prescription drug plan 

administrator. Through their nationwide network community 

and chain pharmacies, and their mail-service pharmacy option, 

you have the broadest choice of pharmacies to choose from to 

satisfy your prescription drug needs.

PHARMACY COPAYMENT

Effective 8/1/2005 AmeriCorps*NCCC members will be 

responsible for a $5.00 copay for each prescription drug 

purchased.

HOW TO FILL A PRESCRIPTION

Your health care identification card contains all of the 

information your pharmacist needs. Simply present your card 

to have your prescriptions filled at any one of the network 

pharmacies in your area. The pharmacy will then electronically 

transmit a claim for that medication and within minutes have 

approval for filling the prescription.

You may obtain up to a one-month supply of your prescription 

medication from a retail network pharmacy and up to a threemonth supply through the PharmaCare Direct Mail Service. 

Your health plan requires that all maintenance medications 

or medications taken on an ongoing basis must be purchased 

though the PharmaCare Direct Mail Service. You may obtain 

the application online at www.americorps.sevencorners.com, 

click on “Forms”, and then click on the “PharmaCare Direct 

Mail Service” form. You may also access the online application 

at www.pharmacare.com, click on “PharmaCare Direct”, then 

click on “Enroll”.

HOW TO FIND A PARTICIPATING 

PHARMACY

The PharmaCare network includes over 53,000 pharmacy 

locations nationwide. A listing of participating pharmacies is 

included beginning on this page. To locate the pharmacy nearest 

you, consult this listing, visit the PharmaCare website at www.

pharmacare.com or call member services at 1.800.777.1023.

For each initial prescription or refill obtained at a network 

pharmacy you may obtain up to a one-month supply of your 

medication.

A & P U.s.

Accesshealth

Accredo Health Group, Inc

Acme Pharmacy

Albertson’s, Inc

Allcare/Malone’s Pharmacy

Allina Community Pharmacies / 

MBP, Inc

Allscripts, LLC

American Drug Stores, Inc

Anchor Pharmacies

Appalachian Regional Health Care

Arbor Drugs, Inc.(Acq.by CVS)

Atlas Drugs

Aurora Pharmacy, Inc

B & R Stores, Inc

Balls Four B Corp / Price

Chopper / Hen House

Bartell Drug Company

Baystate Pharmacy

Big “A” Drugstores, Inc

Big Y Foods, Inc

Bi-lo Holding, Llc

Bi-mart Corporation

BJ’s Wholesale Club, Inc

Brooks Pharmacy/Maxi Drug, Inc

Brookshire Brothers Pharmacy

Brookshire Grocery Co

Bruno’s Pharmacy

Buehler Pharmacies

Buehler’s Foods, Inc

Buffalo Pharmacies

Care Pharmacies, Inc (Independents)

Caremark Inc Therapeutic Svcs

Carle Rx Express Pharmacy

Carrs Quality Centers

Cbc Professional Pharmacy, Inc

Chronimed Holding, Inc Dba 

Statscript Phcy

City Market / Dillon Companies

CJM Incorporated

Coborns, Inc

Columbus Health Services Inc.

PRESCRIPTION DRUG

PROGRAM 7

Community Dist, Inc/drug Fair

Community Pharmacies, Lp

Costco Pharmacies

Curascript Pharmacy, Inc.

CVS

D & W Food Centers, Inc.

Dahl’s Foods

Dartmouth Hitchcock Phcy Admin.

Davidson Drugs, Inc.

Department Of Veterans Affairs

Dierberg Family Markets, Inc

Dillon’s Pharmacy

Discount Drug Mart, Inc

Doc’s Drugs

Dominick’s Finer Foods, Inc

Drug World Pharmacies

Duane Reade

Duluth Clinic

Eaton Apothecary

Eckerd Drug Company

Epic Pharmacy Network, Inc.

Fagen Pharmacy

Fairview Pharmacy Services

Fairview Pharmacy Services, LLC

Family Care Plus

Familymeds, Inc

Farm Fresh Pharmacy

Felpausch Pharmacy

Fitzgerald’s Pharmacy (F & F 

Pharmacies)

Food Lion Pharmacy

Fred Meyer, Inc

Fred’s, Inc

Fruth Pharmacy

Fry’s Food & Drug (Kroger Corp)

Gemmel Pharmacy Group, Inc

Giant Eagle, Inc

Giant Food Stores, LLC

Giant of Maryland, LLC

Golub Corporation / Price Chopper

Greco Enterprises, Inc

Gristedes Pharmacy

WHAT YOU SHOULD DO IF YOUR 

PHARMACY IS NOT PART OF THE 

PHARMACARE NETWORK

In the unlikely event a pharmacy in your area is not part of 

our network then please ask your pharmacist to request a 

participation agreement by calling PharmaCare’s Network 

Service Department at 1.800.237.6184 x7555.

A list of participating pharmacies, including national and 

regional chain drug stores, begins on this page.
Gu Markets, LLC

H.e.b Grocery

Haggen, Inc

Hannaford Brothers, Inc (Shop & 

Save)

Happy Harry’s Inc

Harmons Pharmacy

Harp’s Food Stores, Inc

Harris Teeter Pharmacy

Hartig Drug

Healtheast Pharmacies

Henry Ford Health System 

Pharmacies

His Infusion Services dba 

Ambulatory Pharmaceutical Serv.

Hi-School Pharmacy

HLS Pharmacies, Inc

Homeland Stores, Inc

Horton & Converse

Hy-vee, Inc.

Ingles Markets, Inc

Integrity Healthcare Services, Inc

Intermountain Health Care

J.H. Harvey Co., LLC

Kash N Karry Food Stores, Inc.

Kelsey-Seybold Pharmacy

Kerr Drug, Inc.

Keystone Med-chest

King Kullen Pharmacies Corp

King Soopers, Inc.

Kinney Drugs, Inc.

Kleins Pharmacy

Klingensmith’s Drug Stores, Inc

K-mart Corporation

Knight Drugs, Inc

Kohll’s Pharmacy & Homecare

Kopp Pharmacy

Kroger Co Corporate

K-VA-T Food Stores, Inc dba Food 

City Phcies

Leader Drug Stores

Lifechek Drug

Longs Drug Stores (Except Ca, Hi)

Louis & Clark Drug

M.K. Stores, Inc

Major Value Pharmacy Network

Managed Pharmacy Care

Marc Glassman, Inc

Market Basket Pharmacies

Marsh Drugs, LLC

Marshfield Clinic Pharmacy

Martin’s Super Markets, Inc

Maxor National Pharmacy

May’s Drug Stores, Inc

Mckesson Valurite Pharmacies

Med-fast Pharmacy

Medic Drug, Inc

Medicap Pharmacies, Inc

Medicap Pharmacy / Company 

Owned

Medicine Centers Of Atlanta, 

Inc Dba Traceys Medicine Ctr

Medicine Shoppe

Medicine Shoppe Poi

Mediserv, Inc

Med-x Corporation/Drug Mart

Meijer, Inc

Memorial Sloan Kettering

Mercy Health System Retail 

Pharmacies

Metro Pharmacy

Minyard & Sack ‘N Save 

Pharmacies

Moore & King Pharmacy

Morton Drug Company, Inc

Nash Finch Company/

Ekicksons

Navarro Discount Pharmacies

NCS Healthcare

Neigborcare Pharmacies

Network Pharmaceuticals Dba 

Network Phcy

Northwest Health Ventures, Inc 

/ Lehman

Nova Factor, Inc

Oakwood Pharmacy, Inc

Omnicare, Inc

Oncology Pharmacy Services, 

Inc (Form:tops Phcy)

Owl Drug Stores, Inc

P & C Food Market - Penn 

Traffic Co

Pacmed Clinic Pharmacies

Pamida Pharmacy

Park Nicolett Pharmacies

Pathmark Stores, Inc

Pavilion Plaza Pharmacies

Payless Drug Stores

Payless Drugs

Pediatric Services Of America, 

Inc

Peoples Pharmacy

Pharma-card Mgmt Services, Inc

Pharmacare Pharmacy

Pharmacare Specialty Pharmacy

Pharmacy Express Services, Inc

Pharmacy Plus

Pharmacy Providers Of OK

Pharmerica, Inc.

Piggly Wiggly Carolina Co, Inc / 

Price Wise

Professional Village Pharmacy, 

Inc

Publix Super Markets, Inc

Quality Food Centers, Inc

Quality Markets - Penn Traffic Co

Quick Chek Food Stores

Raleys Drug Center/Bel Air

Ralph’s Pharmacies

Randall’s Food & Drugs, Inc

Recept Pharmacy, LP

Revco (Acq. By CVS)

Ridley’s Food Corporation

Rinderer’s Drug Stores, Inc

Risch Drug Stores, Inc

Rite Aid Corporation

Ritzman Pharmacies, Inc

Riverside Div of Penn Traffic (Bi-lo)

Rogers Pharmacies

Rosauers Supermarkets, Inc

RPCS, Inc

Rx Plus

Rxd Pharmacy

Rxpride, Llc

Safescript Pharmacy/RTIN 

Holdings, Inc

Safeway, Inc

Save Mart Supermarkets

Sav-mor Drug Stores

Schnucks Pharmacy

Scolari’s Food & Drug Co

Seaway Food Town, Inc

Sedano’s Pharmacies

Sedell’s Pharmacy

Shelby Shore Drugs, Inc dba Family 

Drug Stores

Shelly’s Pharmacies

Shopko Stores, Inc

Shoppers Pharmacy

Shoprite Pharmacy (Wakefern)

Smith’s Food & Drug Centers, Inc

Snyder’s Drug Stores, Inc

Sparten Retail (Form:Family Fare/

glen’s Phcy) 

St John Health System

St Joseph Mercy Pharmacy

Star Markets dba Shaws Pharmacy

Stewart Memorial Community 

Hospital

Sunscript Medical Services

Sunscript Pharmacy

Super D Drugs, Inc

Supermarket Investors, Inc dba 

Harvest Foods

Supervalu Pharmacies

Target Stores

The Pay-less Pharmacy Group

The Pharmacy Cooperative

The Stop & Shop Supermarket Co, 

LLC

Third Party Station

Third Party Station-CP

Thrifty Drug

Thrifty Drug Stores, Inc

Tidyman’s, LLC

Tom Thumb Food & Pharmacy

Tops, Inc

Truecare Pharmacy-NR

Twin Knolls Pharmacy, Inc

Ukrop’s Supermarkets Inc

United Drugs

United Supermarkets, Ltd

Unity Retail Pharmacies

University Health System 

Pharmacies

University Of Utah Health

Usa Drug

Usa Drug/M & H Drugs

U-Save Pharmacy

UW Health Outpatient Pharmacy

Vaden Corp dba Med-RX Drug

Valu Merchandisers/A W G 

Network

Von’s Companies, Inc

Walgreen Drug Stores

Wal-mart

Wayne Drug Co.

Wayne-Oakland Pharmacy Mgmt

Weber & Judd Kahler Co, Inc

Wegmans Food Markets, Inc

Weis Markets, Inc

Western Drug Distrib dba Drug 

Emporium NW

Winn Dixie Stores, Inc.

Yoke’s Washington Foods, Inc.

PRESCRIPTION DRUG

PROGRAM 8
WHAT ABOUT GENERICS?

Are generic drugs as effective as brand name drugs? Almost 

always, the answer is “yes”. Not every medication is available 

as a generic alternative, but many of the most commonly 

prescribed medications are. You can help lower your cost, and 

the cost AmeriCorps pays each year for medications, by using 

generics whenever possible. When you need a new prescription, 

ask your doctor whether a generic can be substituted for a 

brand name. You can also ask your pharmacist. In many cases 

they can substitute a generic for the brand without further 

approval. In some cases your pharmacist may need your doctor’s 

permission.

MAIL SERVICE PHARMACY

Mail-Service pharmacy provides a convenient way for you to 

have your medication delivered right to your home or office. 

PharmaCare Direct should be the first choice for people 

using maintenance medications. These are medications taken 

on an ongoing basis such as asthma, heart and cardiovascular 

conditions, diabetes and even oral contraceptive medications. 

And with mail-service you are authorized 90 day supplies of 

your medications at each fill.

To start using mail-service you’ll need a prescription from your 

doctor for each medication. Ask your doctor to authorize a 90 

day supply and four refills. Be sure to also obtain a prescription 

for an initial fill at your local pharmacy if you need to use the 

medication right away or don’t have existing supplies of your 

medications at each fill.

To obtain a PharmaCare Direct enrollment kit, contact 

AmeriCorps Customer Service toll free at 1.866.699.4186

or enroll directly on-line using the easy to complete on-line 

enrollment form found at www.pharmacare.com.

PRESCRIPTION DRUG PROGRAM 

EXCLUSIONS

❖ Any over-the-counter drug that can be bought without a 

prescription.

❖ Therapeutic devices or appliances or other non-medical 

substances, regardless of their intended use.

❖ Nonprescription contraceptives and supplies related to 

birth control, injectable and implantable contraception, 

with the exception of birth control pills and diaphragms 

which are covered.

❖ Drugs used to deter smoking.

❖ Anorexiants, anti-obesity drugs.

❖ Any drug for cosmetic purposes, including, but not 

limited to, Rogaine.

❖ Any quantity of drugs dispensed which exceeds the 

supply and refill limits.

❖ Any prescription or refill dispensed more than one year 

after the original prescription.

❖ Prescriptions filled prior to the effective date or after the 

termination date of the member’s coverage.

❖ Drugs labeled “Caution-Limited by Federal Law to 

Investigational Use,” drugs which are experimental or 

investigational in nature, or which are in connection 

with experimental or investigative services or supplies, 

including drugs requiring federal or other governmental 

agency approval not granted at the time they are 

prescribed.

❖ Related services or supplies including, but not limited to, 

administration of high dose chemotherapy, radiation therapy, 

or any other form of therapy, or immunosuppressive drugs 

are not covered when associated with any tissue or solid 

organ transplant procedure.

❖ Immunization agents 

❖ Biological sera

❖ Unreceipted blood, blood plasma or blood expanders.

❖ Betaseron, Avonex, Copaxone, Tysabri

❖ Fertility drugs

❖ Fluoride preparations

❖ AIDS-related drugs

❖ Non-insulin syringes/needles

❖ Vitamins, vitamin A derivatives

❖ Human growth hormones

❖ All drugs related to Erectile Dysfunction (ED)

PRESCRIPTION DRUG

PROGRAM 9
Abortion or Sterilization Surgery

Acupuncture Therapy

Alcohol, Drug Abuse or Detoxification Treatment - For 

services beyond what is covered under hospital coverage. (see 

page 2)

Allergy Tests or Injections - Any services related to the 

treatment of allergies including allergy tests and surveys, injection, 

medication and treatment (except for emergency treatment 

including medication and hospitalization for asthma).

Biofeedback Therapy

Cardiac Rehabilitation Services

Chiropractic Services 

Contraceptives - Charges for non-prescription contraceptives.

Cosmetic Surgery - Any services performed in connection with 

cosmetic surgery (except for conditions required for the repair 

of accidental injury suffered while the member is enrolled) for a 

non-functional condition or for any condition that existed on the 

effective date of the member’s coverage.

Counseling - For marriage or parent counseling or evaluation. 

Exception: See Mental Health Services under Covered Services, 

page 3.

Equipment (DME) - Purchase or rental of equipment such as 

air conditioners, humidifiers, purifiers or similar devices.

Experimental Procedures - Any treatment or supplies which 

are experimental or unproven by scientific evidence or generally 

not accepted by informed health care professionals as effective 

in treating the condition, diagnosis or illness for which their use 

is proposed.

Feet - Expenses incurred in connection with weak, strained or 

flat feet, corns, calluses or toenails. Orthopedic shoes and other 

supportive devices for the feet. This does not apply to infections 

of the toenails or feet and does not apply to casts, splints or 

braces for treatment of injuries.

Hemodialysis - For Chronic Renal Failure and End Stage Renal 

Disease

Home Health - Unless a covered inpatient service is less 

expensive when administered at home.

Hospice Care

Hospital Care - When primarily for diagnostic purposes 

(unless the condition or type of tests require hospitalization), 

convalescent or custodial care (unless in conjunction with 

regular hospital confinement within the previous seven days), 

institutional care, rest or rehabilitation. Also hospitalization 

primarily for physical therapy or occupational therapy, unless 

the therapy could not have been provided on an outpatient 

basis and the complexity of the member’s condition required 

additional skilled care.

Immunizations - Required for travel outside of the United 

States

Newborn - Complications affecting the infant.

Nursing - Private duty nursing care or services of special 

nurses and payment for their meals.

Obesity or Weight Reduction Treatment

Orthopedics - Shoes or other supportive devices for the feet.

Physicals - Care provided as part of an annual or routine 

physical examination including routine lab work. Exception: 

See Preventative Care under Covered Services on page 3. 

Preconception Services or Supplies - For the purpose of 

inducing pregnancy, such as “in vitro” (test tube) fertilization, 

artificial insemination or experimental services.

Pre-existing Conditions - Benefits are not paid for preexisting conditions. A pre-existing condition is any condition 

or illness for which medical treatment was given, or a diagnosis 

was made, on or before the effective date of coverage. 

Personal Comfort Items - Any personal comfort item 

(purchased or rented) such as a telephone, television, air 

conditioner, dehumidifier, air cleaner, barber or beauty 

services.

EXCLUSIONS TO

COVERED SERVICES 10

Note: Medical necessity is required. (see page 14)
Exclusions to Covered Services (continued)

Services or Supplies - 

❖ Which are not medically necessary for the diagnosis 

or treatment of an illness

❖ Provided by a member’s spouse, parent, sibling or 

child

❖ Filed for payment later than two years from the date 

the services were provided

❖ Which would not have been incurred if the patient 

did not have this coverage

❖ Eligible for payment under worker’s compensation 

benefits

❖ Related to a military service disability or other 

condition resulting from war

❖ Provided in an extended care facility

❖ For room or board in an institution that is not a 

hospital

❖ When benefits are available under a personal injury 

protection contract

❖ No-fault motor vehicle insurance

❖ Any private group health insurance plan

❖ As a result of subrogation from liable third parties. 

Sexual Transformations, Sexual Impairment or 

Inadequacy Treatment

Skilled Nursing/Extended Care

(Unless a covered service is less expensive when administered 

under skilled nursing or extended care.)

Surgery - Services that are not medically necessary.

Temporomandibularjoint Disease (TMJ) - Medical or 

dental services or supplies for the treatment of TMJ.

Transplant, tissue or solid organ - Services or supplies for or 

related to any tissue or solid organ surgical transplants and any 

complications resulting from any such procedures including, but 

not limited to, heart, lung, kidney, pancreas, cornea, liver, bone 

marrow, (autologous or allogeneic for any diagnosis), skin graft 

and bone grafts. Related services or supplies including, but not 

limited to, administration of high dose chemotherapy, radiation 

therapy, or any other form of therapy, or immunosuppressive 

drugs are not covered when associated with any tissue or solid 

organ transplant procedure.

Transportation - Other than covered ambulance service.

HOW TO 

SUBMIT A CLAIM 11

Vision - Services or supplies for the medical or surgical 

treatment of myopia (nearsightedness) or hyperopia 

(farsightedness) including, but not limited to, radial 

keratotomy and the other forms of refractive keratoplasty, 

including laser surgery.

COORDINATION OF BENEFITS

Most group health care programs, including this 

program, contain a Coordination of Benefits provision. 

This provision is used when you are eligible for payment 

of claims under more than one group health program. 

Coordination of benefits assures that your covered 

expenses will be paid, but that the combined payments 

of all of the programs do not amount to more than 

the actual cost of your care. Coordination of benefits 

prevents duplicate payments and helps control the cost 

of health care coverage.

When you have health care coverage from two or more 

insurance carriers, coordination of benefits determines 

which carrier is the primary payer and must pay claims 

up to the limit of its policy. The other insurer is then 

designated as the secondary payer and must pay any 

remaining amount covered by the plan.

If you have health care coverage other than this 

AmeriCorps plan, use the following guidelines to 

determine when claims should be submitted to 

AmeriCorps as the primary payer:
HOW TO SUBMIT YOUR CLAIMS

Claims are automatically submitted for you when you use a 

PPO network provider. You will not be responsible for charges 

(except for your copayment) over the usual, customary and 

reasonable charges. All covered services are paid according to 

the negotiated fee schedule. Payment will not be expected in 

advance.

If you have a claim from a non-PPO network provider, 

complete the AmeriCorps claim form and attach all of the 

itemized original bills needed to support your claim. If you 

need additional claim forms, please call Customer Service at the 

number on page 1 of this guide or download a form from the 

web site at www.americorps.sevencorners.com.

Itemized original bills must be submitted to verify the 

information we need to process your claim. Cancelled checks 

are not acceptable proof of a claim. Bills do not need to be 

marked paid before you can claim your benefits. 

Original bills will not be returned. Keep a photocopy of all 

bills and receipts for your personal records. Claims must be 

filed for reimbursement no later than two years from the date 

the services were provided. The bills you submit must include 

the following information:

a) Name, address and professional status of the person or 

organization providing the service

b) Provider Tax ID number

c) Name of patient receiving service

d) Date of service

e) Description of each service

f) Diagnosis

g) Charge for each service

h) For eligible psychotherapy expenses, include the length of 

each session and session type (ex., group or individual)

Sign the completed claim form and mail it to the address 

on the back of your identification card. (Note: claims for 

emergency dental services should be sent directly to the address 

on the back of your identification card.)

Requests for reimbursement of pharmacy prescriptions require 

completion of the pharmacy claim form found in the back of 

this guide. See pharmacy form for required information and 

mailing address.

DO YOU HAVE OTHER HEALTH 

INSURANCE COVERAGE?

1st: Submit claims to private insurance carrier.

2nd: Submit remaining charges to the AmeriCorps plan 

 using the claim address on the back of your 

identification card. 

DO YOU RECEIVE MEDICARE 

BENEFITS OR MEDICAID BENEFITS?

If you become disabled prior to age 65 or are otherwise 

entitled to Medicare benefits (ex., for renal dialysis), the 

benefits you are entitled to receive from Medicare will be 

reduced by the amount AmeriCorps would pay.

You must first use the AmeriCorps health plan benefits 

to which you are entitled before submitting charges to 

Medicare or Medicaid for reimbursement.

HOW TO

SUBMIT A CLAIM 12

Coordination of Benefits (continued) 
APPEALING A PRECERTIFICATION 

DECISION

Should you or your physician not agree with the precertification 

decision, you have the right to appeal. The appeal process is 

available for continued stay requests or for future admissions 

or procedures. The appeal may be initiated by you, your 

attending physician or the utilization review staff of the 

facility where the service is performed.

The appeal can be initiated by telephone, fax or other means 

of rapid communication. The appeal should occur prior to 

the service or admission and, for a continued stay, prior to 

discharge from the facility. The decision will be communicated 

via telephone to the attending physician and the utilization 

review department of the facility within 24 hours of receipt 

of all necessary information.

APPEALING A CLAIMS DECISION

Decisions regarding benefit eligibility are generally made 

within two to three weeks after receiving a claim. In 

special situations, additional time may be needed to make 

benefit determinations regarding your claim. If a benefit 

determination decision is delayed for more than 90 days, a 

notice will be sent to you explaining the reason for delay.

If any claim or portion of a claim is denied, you will 

receive an explanation of the denial. You may request 

further explanation or provide additional information to be 

considered regarding your claim.

How to appeal your claim – You or your authorized 

representative may appeal a denial of benefits for any claim or 

portion of a claim by sending your appeal and any additional 

information related to the claim and comments in writing 

to: 

AmeriCorps 

Attn: Appeals

P.O. Box 3430

Carmel, IN 46082-3430

APPEAL

PROCEDURES

& SUBROGATION 13

SUBROGATION

If the member is injured or becomes ill through the act or 

omission of another person, and if benefits are paid under 

this plan due to that injury or sickness, then to the extent 

the member recovers for the same injury or sickness from a 

third party, its insurer, or the member’s uninsured motorist 

insurance, AmeriCorps will be entitled to a refund from such 

recovery of all benefits it has paid.

AmeriCorps may file a lien in a member’s action against a 

third party and have a lien upon any recovery that the member 

receives, whether a settlement, judgment or otherwise, and 

regardless of how such funds are designated. AmeriCorps 

shall have a right to recovery of the full amount of benefits 

paid under this program for the injury or sickness, and that 

amount shall be deducted first from any recovery made by 

member. AmeriCorps will not be responsible for the member’s 

attorney’s fees or other costs.

Upon request, the member must complete the required forms 

and return them to AmeriCorps. The member must cooperate 

fully with AmeriCorps in asserting its right to recover. The 

member will be personally liable for reimbursement to 

AmeriCorps to the extent of any recovery obtained by the 

member from any third party. If it is necessary for AmeriCorps 

to institute legal action against the member for failure to repay 

AmeriCorps, the member will be personally liable for all costs 

of collection including reasonable attorney’s fees. 

CONVERSION

Upon termination from service, you may convert from your 

health plan provided by CNCS to a private plan administered 

by Celtic Life Insurance Company. This conversion option is 

available for those who do not have other insurance options. 

Your option to convert to private insurance must be exercised 

within 30 days of the date of termination from service. You are 

responsible for meeting this deadline. No reminder notification 

will be provided to you. You may receive information by 

calling toll free 1.800.365.2365 or online at www.americorps.

sevencorners.com, click on “Forms”, then click on Conversion 

Coverage.

Note: COBRA coverage is not available through CNCS.
Medically Necessary or Medical Necessity - Services 

or supplies, provided by a provider facility or an individual 

provider, which are required for treatment of illness, injury, 

diseased condition or impairment and are:

1. Consistent with your diagnosis or symptoms;

2. Appropriate treatment, according to generally accepted 

standards of medical practice;

3. Not provided only as a convenience to you or to the 

provider;

4. Not experimental or unproven; and

5. Not excessive in scope, duration or intensity to provide 

safe, adequate and appropriate treatment. Any service or 

supply provided at a provider facility will not be considered 

medically necessary if your symptoms or condition 

indicates that it would be safe to provide the service or 

supply in a less comprehensive setting.

Medicare - The program of health care for the aged and 

disabled established by Title XVIII of the Social Security Act 

of 1965, as amended.

Outpatient - An insured who is a patient, other than a bed 

patient, at a provider facility.

Preferred Provider - Providers of service who have been 

selected or have decided to become part of a preferred network 

to work with an insurer to help control costs to patients.

Pre-Existing Condition - A pre-existing condition is any 

condition or illness for which medical treatment was given, 

or a diagnosis was made, on or before the effective date of 

coverage. 

Exception: All members who are medically terminated and 

reinstated at a later date will have the condition for which they 

were medically terminated covered by the health plan.

Benefit Year - The one-year period that begins on your start date 

in the AmeriCorps*VISTA or AmeriCorps*NCCC program. 

You accumulate your inpatient room and board benefits in this 

period of time.

Copay - The amount the member is responsible to pay for 

each medical office visit.

Covered Charges - Charges that are not excessive for covered 

services. Judgment will be based on one or a combination of the 

following: a negotiated rate based on services provided; a fixed 

rate per day; or the usual, customary and reasonable allowance 

for similar providers who perform like covered services.

Covered Services - Services or supplies for which benefits will 

be paid when provided by a provider acting within the scope of 

his/her/its license. In order to be considered a covered service, 

charges must be incurred while your coverage is in force.

Exclusions - Any service or supply related to pre-existing 

conditions or other non-covered plan benefits.

Experimental - Any treatment, procedure, facility, equipment, 

drug, device or supply which:

1. Is not accepted as standard medical treatment for the 

condition being treated; or 

2. Requires but has not received federal or other governmental 

agency approval at the time of service.

Identification Card - A card issued by the AmeriCorps 

health care plan that bears the member’s name, identifies the 

membership by number and may contain information about his 

or her coverage.

GLOSSARY

14 OF TERMS
GLOSSARY 

OF TERMS 15

Spike - Assignment to projects away from your NCCC regional 

campus.

Usual, Customary and Reasonable (UCR) - The allowance 

measured and determined by comparing actual provider 

charges with the charges customarily made for similar services 

and supplies to individuals with similar medical conditions. 

When covered charges are based on the UCR allowance, the 

AmeriCorps health care plan will pay the UCR allowance or 

billed charges, whichever is less.

Approved Providers of Service - When you are ill or injured, 

your coverage helps pay the hospital and your physician as 

well as appropriate charges for other approved health care 

professionals. These providers include but are not limited to:

Hospital – any hospital accredited by the Joint 

Commission on the Accreditation for Health 

Organizations, including Veterans Administration 

Hospitals and Department of Defense Hospitals.

Physicians – any provider licensed in the state where 

the services were provided. These include: Doctor of 

Medicine (MD), Doctor of Osteopathy (DO), Doctor 

of Dental Surgeries (DDS or DMD), Podiatrist (POD) 

and Psychologist (Ph.D.).

Certified Nurse Midwife – Must be a licensed registered 

nurse and certified as a nurse midwife by the American 

College of Nurse Midwives.

Other Providers – Nurse anesthetist, nurse practitioner, 

psychiatric social worker, respiratory therapist, speech 

therapist, occupational therapist, optician, optometrist, 

physicians’ assistant, private duty nurse, technical surgical 

assistant, registered physical therapist or physiotherapist. 

All of the above mentioned providers must be licensed 

or certified in the jurisdiction where the services were 

provided.
YOU SHOULD KNOW ...

ABOUT PRE-EXISTING CONDITIONS

AmeriCorps does not provide benefits for any diagnosis 

that is considered a pre-existing condition. A pre-existing 

condition is any condition or illness for which medical 

treatment was given, or a diagnosis was made, on or 

before the effective date of coverage. 

Exception: All members who are medically terminated 

and reinstated at a later date will have the condition for 

which they were medically terminated covered by the 

health plan.

If a claim is submitted that appears to be a pre-existing 

illness or condition, medical records will be required to 

make a determination. 

ABOUT EMERGENCY ROOM TREATMENT

If you seek emergency room treatment and are not 

immediately admitted to the hospital, you are responsible 

for a $25 copay prior to benefits being paid (this $25 

copay is waived for AmeriCorps*NCCC members). 

ABOUT PRECERTIFICATION REQUIREMENTS

Failure to consult and obtain precertification of 

your inpatient hospital admission will result in a $300 

reduction in benefits. You will be responsible for paying 

this amount.

ABOUT PREVENTIVE CARE COVERAGE

The AmeriCorps health care plan pays for only the 

following preventive / routine care services for female 

members:

1. One GYN health visit per service year that 

includes one pelvic examination, Pap smear, breast 

examination and lab work related to GYN health 

when performed at the time of the annual GYN 

exam. Contraceptive management is covered only

when performed at the annual GYN health visit.

2. One mammogram for women over 40 is covered 

per service year. All other routine mammograms are 

not included as part of these services.

For males over 50, one prostate examination, including a 

PSA, is covered by the plan per service year. 

CLAIM FORMS

This guide provides two copies of the 

AmeriCorps claim form. Please detach one copy 

for your provider and keep the other for times 

when you may need to submit a claim yourself.

Additional claim forms can be requested by calling 

Customer Service toll free at 1.866.699.4186 or 

download a form from the web site at www.

americorps.sevencorners.com.

NOTES:
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Prescription Reimbursement Claim Form

Important! *Always allow up to 30 days from the time you send this form until the time you receive the response to

allow for mail time plus claims processing.

*Keep a copy of all documents submitted for your records.

* Do not staple or tape receipts or attachments to this form. 

STEP 1 Card Holder/Patient Information This section must be fully completed to ensure proper reimbursement of your claim. 

Address

City State Zip Code

(refer to your prescription card)

Name (Last Name) (FirstName) (MI)

Group No./Group Name

Date of Birth Male Female

Name (Last Name) (FirstName) (MI)

Card Holder Information

Patient Information–Use a separate claim form for each patient

4423-0808 1

STANDARD

REVISED 02/2009

(Over)

Important! A signature is REQUIRED

NOTICE

Any person who knowingly and with int

insurance or statement of claim containing any materially false information or conceals for the purpose of misleading

information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects

such person to criminal and civil penalties.

I certify that I (or my eligible dependent) have received the medicine described herein and that the plan participant

information entered on this form is true and correct.

x

Signature of Plan Participant Date

Phone Number

Identication Number
MailingInstructions:

IMPORTANT REMINDER

To avoid having to submit a paper claim form:

• Always haveyour cardavailableat timeofpurchase

• Alwaysusepharmacies within your network

• Use medication from your formularylist

• Ifproblemsareencounteredat thepharmacy, call the numberon thebackofyour card

CVSCaremark

P.O. Box52010

Phoenix, Arizona85072-2010

RXBIN # 610468 mail to:

1.Patient Name 4.Prescription Number 7. Medicine NDC number

2. DateofFill 5. Metric Quantity 8. DaysSupply

3.TotalCharge 6.Pharmacy Nameand AddressorPharmacy NABP Number

You MUSTincludealloriginal receipts foryour claim toprocess.You MUSTincludeyour pharmacyreceipt. Cash register receipts

 will only be accepted for diabetic supplies.The minimum information requiredis:

If Foreign Claim : Country:_______________ Currency:_______________ Amount:_______________ 

STEP 2

STEP 3

Submission Requirements:

DS 15

John Smith

1234 West Way Washington, DC 85001

1234WestWayWashington,DC85001

1234567

4. PERSCRIPTION #

1. PATIENT NAME

7. NDC #

8. DAYS SUPPLY 5. QUANTITY

3. TOTAL CHARGE

2. FILL DATE

6. DISPENSER (Pharmacy Name and Address)

ExamplePharmacy Receipt:
INSTRUCTIONS FOR FILING CLAIM

1. Please fully complete this side of form.

2. Have your doctor complete the back of this form.

3. Mail this form and any other bills to:

AMERICORPS * VISTA

Attn: Claims

P.O. Box 3430

Carmel, IN 46082-3430

4. Please contact this office if you have any questions.

TO BE COMPLETED BY PARTICIPANT ANSWER ALL QUESTIONS THAT APPLY. SIGN WHERE INDICATED BY

Street City State Zip Code

IMPORTANT Identification Number

Are any hospital, surgical or medical benefits or services provided under any group, individual, blanket, school, franchise or no-fault

auto insurance plan or under any state, federal or other governmental program (i.e. Medicaid)? • Yes • ••No

If “Yes”, give the name and address of the insurance company or other organization providing benefits and the policy numbers.

Name__________________________________________________________________ Date of Birth

Home Address

The above information is hereby certified to be true and complete. I agree to reimburse my health plan if this claim for sickness/injury is

compensable under Medicare-Medicaid, the Worker's Compensation Act or similar law, if benefits excluded by the provisions of the contract

are paid, if such claim is settled or compromised or in the event of recovery from a third party.

Date Participant's Signature

I permit any physician, pharmacist, hospital or other health care provider, any insurer, prepayment organization or other health plan

provider to give my health plan or its representative any medical information about the patient listed above, including information about

physical and mental health, medical history and drug or alcohol use. This information will be used to evaluate claims for benefits.

This authorization will remain in effect until all matters relating to these claims are concluded. A copy of this authorization will be as valid as

the original. I understand that I may receive a copy of this authorization if I ask for one in writing.

Date Participant's Signature

TNAPI CI TRAP

NOI TA

MROFNI

ECNARUSNI

NOI TA

MROF IN

Are you covered under Social Security

(Medicare) Health Insurance?

• Yes • No

Identification Number:_______________

If “Yes,” indicate your coverage by checking

the appropriate boxes:

• Hospital Only (Part A)

• Medical Only (Part B)

• Hospital and Medical (Part A & B)

Effective Date: ____________________

Are you covered under any other

health insurance?

• Yes • No

Identification Number: ______________

Effective Date: ___________________

Was medical condition related to:

A. Employment • •Yes • No

B. Accident • •Yes • No

Are you covered under

medical assistance (Medicaid)?

• Yes • No

Identification Number: _______________

Effective Date: ____________________

Date of Accident: __________________

Describe illness, injury or symptoms: _________________________________

____________________________________________________________

____________________________________________________________

Date symptoms first appeared: _____________________________________

OT NOI SSI MREP

OFNI NI ATBO

TOTAL CHARGES submitted with this form: $ _____________________________ Issue Payment to:••• •Participant • Provider

NOTE: To expedite the processing of your claim pleasemake sure the diagnosis code, procedure code and providerÕs PIN# are included on the claim and/or receipts.

First Middle Initial Last Month Day Year

P.O. Box 3430

Carmel, IN 46082-3430 

1.866.699.4186
HEALTH CLAIM FORM

READ INSTRUCTIONS BEFORE COMPLETING OR SIGNING THIS FORM

TYPE OR PRINT • MEDICARE • MEDICAID • CHAMPUS • OTHER

PATIENT & PARTICPANT INFORMATION

1. PATIENT'S NAME (First name, middle initial, last name) 2. PATIENT'S DATE OF BIRTH 3. PARTICIPANT'S NAME (First name, middle initial, last name)

7. PATIENT'S RELATIONSHIP TO PARTICIPANT 8. PARTICIPANT'S GROUP NO. (Or Group Name)

SELF SPOUSE CHILD OTHER

9. OTHER HEALTH INSURANCE COVERAGE — Enter Name of Policyholder

and Plan Name and Address and Policy or Medical Assistance Number

10. WAS CONDITION RELATED TO

A. PATIENT'S EMPLOYMENT

• Yes • ••No

B. AN AUTO ACCIDENT

• Yes • ••No

11. PARTICIPANT'S ADDRESS (Street, city, state, zip code)

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED

I Authorize the Release of any Medical Information Necessary to Process this Claim and Request Payment of PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW Benefits Either to Myself or to the Party Who Accepts Assignment Below.

SIGNED DATE SIGNED (Participant or Authorized Person)

PHYSICIAN OR SUPPLIER INFORMATION

4. PATIENT'S ADDRESS (Street, city, state, zip code) 5. PATIENT'S SEX 6. PARTICIPANT'S I.D. NO. or MEDICARE NO. (Include any letters)

B*

PLACE OF

SERVICE

A

DATE OF

SERVICE

24. C FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES

FURNISHED FOR EACH DATE GIVEN

PROCEDURE CODE

(IDENTIFY: ) (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES)

D

DIAGNOSIS

CODE

E

CHARGES

F

25. SIGNATURE OF PHYSICIAN OR SUPPLIER 26. ACCEPT ASSIGNMENT 27. TOTAL CHARGE 28. AMOUNT PAID 29. BALANCE DUE

(GOVERNMENT CLAIMS ONLY)

30. YOUR SOCIAL SECURITY NO. 31. PHYSICIAN'S OR SUPPLIER'S NAME, ADDRESS, ZIP CODE &

TELEPHONE NUMBER

SIGNED DATE

32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO.

I.D. NO.

•

•

14. DATE OF: ILLNESS (FIRST SYMPTOM) OR 15. DATE PATIENT FIRST CONSULTED 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?

INJURY (ACCIDENT) OR YOU FOR THIS CONDITION

PREGNANCY (LMP)

17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY

RETURN TO WORK

FROM THROUGH FROM THROUGH

19. NAME OF REFERRING PHYSICIAN 20. FOR SERVICES RELATED TO HOSPITALIZATION

GIVE HOSPITAL DATES

ADMITTED DISCHARGED

21. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (If other than home or office) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?

CHARGES

23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1, 2, 3, ETC. OR DX CODE

1.

2.

3.

4.

*PLACE OF SERVICE CODES

1 - (IH) - INPATIENT HOSPITAL 4 - (H) - PATIENT'S HOME 7 - (NH) - NURSING HOME O - (OL) - OTHER LOCATIONS

2 - (OH) - OUTPATIENT HOSPITAL 5 - DAY CARE FACILITY (PSY) 8 - (SNF) - SKILLED NURSING FACILITY A - (IL) - INDEPENDENT LABORATORY

3 - (O) - DOCTOR'S OFFICE 6 - NIGHT CARE FACILITY (PSY) 9 - AMBULANCE B - OTHER MEDICAL/SURGICAL FACILITY

• Male • ••Female

• Yes • ••No

• Yes • ••No

• Yes • ••No
INSTRUCTIONS FOR FILING CLAIM

1. Please fully complete this side of form.

2. Have your doctor complete the back of this form.

3. Mail this form and any other bills to:

AMERICORPS * VISTA

Attn: Claims

P.O. Box 3430

Carmel, IN 46082-3430

4. Please contact this office if you have any questions.

TO BE COMPLETED BY PARTICIPANT ANSWER ALL QUESTIONS THAT APPLY. SIGN WHERE INDICATED BY

Street City State Zip Code

IMPORTANT Identification Number

Are any hospital, surgical or medical benefits or services provided under any group, individual, blanket, school, franchise or no-fault

auto insurance plan or under any state, federal or other governmental program (i.e. Medicaid)? • Yes • ••No

If “Yes”, give the name and address of the insurance company or other organization providing benefits and the policy numbers.

Name__________________________________________________________________ Date of Birth

Home Address

The above information is hereby certified to be true and complete. I agree to reimburse my health plan if this claim for sickness/injury is

compensable under Medicare-Medicaid, the Worker's Compensation Act or similar law, if benefits excluded by the provisions of the contract

are paid, if such claim is settled or compromised or in the event of recovery from a third party.

Date Participant's Signature

I permit any physician, pharmacist, hospital or other health care provider, any insurer, prepayment organization or other health plan

provider to give my health plan or its representative any medical information about the patient listed above, including information about

physical and mental health, medical history and drug or alcohol use. This information will be used to evaluate claims for benefits.

This authorization will remain in effect until all matters relating to these claims are concluded. A copy of this authorization will be as valid as

the original. I understand that I may receive a copy of this authorization if I ask for one in writing.

Date Participant's Signature

TNAPI CI TRAP

NOI TA

MROFNI

ECNARUSNI

NOI TA

MROF IN

Are you covered under Social Security

(Medicare) Health Insurance?

• Yes • No

Identification Number:_______________

If “Yes,” indicate your coverage by checking

the appropriate boxes:

• Hospital Only (Part A)

• Medical Only (Part B)

• Hospital and Medical (Part A & B)

Effective Date: ____________________

Are you covered under any other

health insurance?

• Yes • No

Identification Number: ______________

Effective Date: ___________________

Was medical condition related to:

A. Employment • •Yes • No

B. Accident • •Yes • No

Are you covered under

medical assistance (Medicaid)?

• Yes • No

Identification Number: _______________

Effective Date: ____________________

Date of Accident: __________________

Describe illness, injury or symptoms: _________________________________

____________________________________________________________

____________________________________________________________

Date symptoms first appeared: _____________________________________

OT NOI SSI MREP

OFNI NI ATBO

TOTAL CHARGES submitted with this form: $ _____________________________ Issue Payment to:••• •Participant • Provider

NOTE: To expedite the processing of your claim pleasemake sure the diagnosis code, procedure code and providerÕs PIN# are included on the claim and/or receipts.

First Middle Initial Last Month Day Year

P.O. Box 3430

Carmel, IN 46082-3430 

1.866.699.4186
HEALTH CLAIM FORM

READ INSTRUCTIONS BEFORE COMPLETING OR SIGNING THIS FORM

TYPE OR PRINT • MEDICARE • MEDICAID • CHAMPUS • OTHER

PATIENT & PARTICPANT INFORMATION

1. PATIENT'S NAME (First name, middle initial, last name) 2. PATIENT'S DATE OF BIRTH 3. PARTICIPANT'S NAME (First name, middle initial, last name)

7. PATIENT'S RELATIONSHIP TO PARTICIPANT 8. PARTICIPANT'S GROUP NO. (Or Group Name)

SELF SPOUSE CHILD OTHER

9. OTHER HEALTH INSURANCE COVERAGE — Enter Name of Policyholder

and Plan Name and Address and Policy or Medical Assistance Number

10. WAS CONDITION RELATED TO

A. PATIENT'S EMPLOYMENT

• Yes • ••No

B. AN AUTO ACCIDENT

• Yes • ••No

11. PARTICIPANT'S ADDRESS (Street, city, state, zip code)

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED

I Authorize the Release of any Medical Information Necessary to Process this Claim and Request Payment of PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW Benefits Either to Myself or to the Party Who Accepts Assignment Below.

SIGNED DATE SIGNED (Participant or Authorized Person)

PHYSICIAN OR SUPPLIER INFORMATION

4. PATIENT'S ADDRESS (Street, city, state, zip code) 5. PATIENT'S SEX 6. PARTICIPANT'S I.D. NO. or MEDICARE NO. (Include any letters)

B*

PLACE OF

SERVICE

A

DATE OF

SERVICE

24. C FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES

FURNISHED FOR EACH DATE GIVEN

PROCEDURE CODE

(IDENTIFY: ) (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES)

D

DIAGNOSIS

CODE

E

CHARGES

F

25. SIGNATURE OF PHYSICIAN OR SUPPLIER 26. ACCEPT ASSIGNMENT 27. TOTAL CHARGE 28. AMOUNT PAID 29. BALANCE DUE

(GOVERNMENT CLAIMS ONLY)

30. YOUR SOCIAL SECURITY NO. 31. PHYSICIAN'S OR SUPPLIER'S NAME, ADDRESS, ZIP CODE &

TELEPHONE NUMBER

SIGNED DATE

32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO.

I.D. NO.

•

•

14. DATE OF: ILLNESS (FIRST SYMPTOM) OR 15. DATE PATIENT FIRST CONSULTED 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?

INJURY (ACCIDENT) OR YOU FOR THIS CONDITION

PREGNANCY (LMP)

17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY

RETURN TO WORK

FROM THROUGH FROM THROUGH

19. NAME OF REFERRING PHYSICIAN 20. FOR SERVICES RELATED TO HOSPITALIZATION

GIVE HOSPITAL DATES

ADMITTED DISCHARGED

21. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (If other than home or office) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?

CHARGES

23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE TO NUMBERS 1, 2, 3, ETC. OR DX CODE

1.

2.

3.

4.

*PLACE OF SERVICE CODES

1 - (IH) - INPATIENT HOSPITAL 4 - (H) - PATIENT'S HOME 7 - (NH) - NURSING HOME O - (OL) - OTHER LOCATIONS

2 - (OH) - OUTPATIENT HOSPITAL 5 - DAY CARE FACILITY (PSY) 8 - (SNF) - SKILLED NURSING FACILITY A - (IL) - INDEPENDENT LABORATORY

3 - (O) - DOCTOR'S OFFICE 6 - NIGHT CARE FACILITY (PSY) 9 - AMBULANCE B - OTHER MEDICAL/SURGICAL FACILITY

• Male • ••Female

• Yes • ••No

• Yes • ••No

• Yes • ••No
FREQUENTLY

USED NUMBERS

CUSTOMER SERVICE:

www.americorps.sevencorners.com

1.866.699.4186

CONVERSION COVERAGE:

1.800.365.2365

PHARMACY LOCATOR:

www.americorps.sevencorners.com

www.pharmacare.net

1.800.777.1023

PHARMACY CUSTOMER SERVICE:

1.800.777.1023

PPO NETWORK PROVIDER SEARCH:

www.americorps.sevencorners.com

1.866.699.4186

PRECERTIFICATION:

1.866.699.4186
Administered by:

3/1/2009

AmeriCorps VISTA

AmeriCorps NCC

C

P.O.Box 3430

Carmel, IN 46082-3430

1.866.699.4186

www.americorps.org

 ́ ́