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Your healthcare questions answered

Have questions about Five Points plans and coverage? Find helpful information for individuals & families, employers, and students - in one place.

For Employers

  • Pharmacy FAQs
    Pharmacy coverage >
  • Member resource FAQs
    Choosing a health care provider > Emergency care > Member benefits and services > Opioid coverage and resources > Personal Health Record >
  • How do I select or change a primary care provider (PCP)?
    You can change your PCP through your secure member account. If you would rather call us, use the number on your Five Points ID card.
  • Can I change my PCP any time I want?
    Yes. Not all plans require you to choose a PCP, but if your plan allows you to choose one, you can change it whenever you want.
  • What if my PCP leaves First Health's network?
    If your physician leaves First Health's network, you will be asked to select another PCP.
  • What if my current doctor doesn't take Five Point's health care coverage?
    Ask your doctor to contact our Member Services office at the toll-free number on your member ID card. One of our Member Services professionals will help your physician get in touch with the appropriate network management office.
  • How do I get a paper provider directory?
    Your employer's benefits office can give you a provider directory for your area.
  • How do I find a participating provider?
    Our online directory can help you find: Doctors (general and specialists) Hospitals and urgent care centers Mental health care Pharmacies Substance abuse treatment Physical therapists Dialysis centers Eye exam providers Medical equipment suppliers Hospice care Hearing discount locations Much more The simplest way to use our online directory is through your secure member account. Once you log in, you're identified by your plan type and the system can easily find providers near you that accept your insurance. You also can use our public directory. It will list all of the plans we offer, and ask you to choose yours. If you're not sure, you can search without choosing a plan by name. If you find a provider in the public directory, we encourage you to contact the provider's office before making an appointment, to confirm that they accept your plan. Use our public online provider directory >
  • What should I do in an emergency?
    If an emergency happens close to home: Call your local emergency hotline (911) or go to the nearest emergency facility. If possible, you should also call your primary care doctor. In all cases, you should contact your primary care doctor as soon as possible after receiving treatment. Once an emergency facility has stabilized your condition, their staff members should try to contact your primary care doctor. Your primary care doctor knows your medical history and is also responsible for coordinating your health care. Please note that all follow-up care should be coordinated through your primary care doctor. If an emergency happens when you're traveling away from home: Remember that urgently needed care is covered while you are traveling outside of your local Five Points service area. You should seek immediate treatment for any illness or injury that would be considered an emergency, or for the care of any urgent problem. If you are admitted to an inpatient facility, you should immediately notify your primary care doctor and Five Points. In other cases, you should notify your primary care doctor and Five Points within 48 hours of an emergency. When seeking emergency care, please note that: Any services you receive must be covered under the terms of your Five Points plan. You are responsible for any emergency room copay. An emergency room copay does not apply when you are admitted for an overnight hospital stay.
  • Do you cover emergency care?
    Yes, we cover emergency care. In fact, emergency care is covered 24 hours a day, seven days a week - anywhere in the world. Generally speaking, an emergency is a situation in which you could reasonably expect that the absence of immediate medical attention could result in serious jeopardy to your health, or if you are a pregnant woman, to the health of your unborn child. This definition may vary based on state regulations.
  • Where can I get a summary of my benefits?
    A summary of benefits and coverage (SBC) shows what your plan covers and your share of the costs. If you have insurance through your job, or your spouse's or partner's job, contact the employer's benefits office. They can give you a summary of benefits. You may be able to find your summary of benefits online.
  • How do I get help from Member Services?
    You have options to get the help you need. For personalized service Call the Member Services number on your ID card. Our representatives are ready to help you. For 24/7 self-service Use our website. The menu prompts will guide you.
  • How can I get a new ID card?
    Your member ID card is always available on your member website. When you log in, you can: Pull up your digital ID card. You can print it or email it. Your digital ID card is the same as your plastic ID card. Request a new ID card. We can send a new plastic ID card to your home.
  • How do I change my primary care physician (PCP)?
    There are two steps to change your PCP: Log in to your member website. You can search for a PCP by ZIP code, language spoken and other preferences. Call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I report a name or address change to my health plan?
    Keeping your name and address up to date with your health plan is important. Here's how to report a change: If you have a Five Points plan through your employer: Let your employer know your name or address has changed. Your employer will send this update to us. If you have a plan that you purchased directly from us (not through an employer): Call Member Services at the number on your ID card. If you have an exchange plan: If you purchased your plan on the Health Insurance Marketplace, contact the plan directly to update your name and address.
  • What happens if my PCP leaves the network?
    Rest assured - if your PCP is no longer in our network, we can help you find another care provider who's right for you. First, log in to choose another PCP who participates with us. We offer an expansive network of doctors to choose from. And you can search by ZIP code, language spoken and other preferences. Next, call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I add a family member to my health plan - or remove a family member?
    You can change your coverage, including adding or removing family members, during the annual Open Enrollment Period. To do so, you'll need to contact your employer. Had a big life even outside the Open Enrollment window? Typically, you can change your coverage within 30 to 60 days of: A marriage or divorce The death of your spouse or dependent The birth or adoption of a child The start or end of your spouse's employment A change from full-time to part-time employment for you or your spouse Unpaid leave of absence for you of your spouse Major change in your coverage, or your spouse's coverage (when caused by your spouse's employment)
  • If I leave my job, where can I find information about continuing my health insurance?
    First, contact your prior employer's benefits office. Let them know you're interested in buying a COBRA (Consolidated Omnibus Budget Reconciliation Act) policy. By federal law, companies with more than 20 employees need to make you aware of your options for buying this coverage.
  • How can I cover my newborn from birth?
    Congratulations to you. Your child is generally covered for 31 days from their date of birth. To continue coverage after this time, you'll need to enroll your child within those 31 days and pay the plan premium.
  • Managing employee benefits FAQs
    Claims Resources > Cobra Coverage and HIPAA guidance > Enrollments, renewals, and quoting > Notification of changes, eligibility and network > Pharmacy management >
  • What should my employee do if a claim is denied?
    Once a claim is denied, the right to appeal is set forth in the initial denial letter. To start the appeals process, the member or a duly authorized representative acting on behalf of the member submits an oral or written request asking for a change in the initial determination decision regarding claim payment, plan interpretation, benefit determination or eligibility. The member, or provider/representative acting on behalf of the member, has 180 days after receipt of a coverage decision to file an appeal, unless otherwise required by law. Within five business days of receipt of a written appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.
  • When traveling, can my employees receive coverage out of area?
    A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay for covered services. No prior authorization or referral is needed. For routine treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also visit a provider without a referral and receive a nonreferred benefit level subject to deductible and coinsurance. We cover emergency care at the preferred level.
  • When will my employees need to file a claim?
    Non-network or out-of-area services: The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our Explanation of Benefits (EOB). Traditional Choice: Members can access care through any licensed provider; there are no networks in this plan. The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our EOB.
  • I have an employee out on disability. How long am I required to keep him/her on the group health insurance policy?
    The length of extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible for COBRA coverage.
  • How are claims handled for employees with more than one health insurance plan?
    Our COB approach is "pursue, then pay." We investigate the availability of other primary benefits before issuing benefits. When other coverage information is obtained, we flag the online family eligibility record. The claim system will then automatically present a COB flag during claim processing. The notice includes details about the other coverage, which family members the other plan covers, the carrier, type of coverage (e.g., medical only, medical-dental, etc.) and date of the last update. When a claim is submitted, if we are secondary and the primary carrier's Explanation of Benefits (EOB) is not attached to the claim, the claim is pended for receipt of the primary carrier's EOB. Upon receipt of the primary carrier's EOB, claims are processed as follows: For maintenance of benefits (MOB) or non-duplication plans, the COB allowable expense is our normal benefit (i.e., our negotiated rate reduced by copays, coinsurance, or other applicable plan provisions). For standard plans, the COB allowable expense is the lesser of the primary plan's negotiated fee (if the primary plan is also a network plan) or the amount submitted to the primary carrier, subject to R&C limitations. Once we determine the allowable expense, we subtract the primary carrier's payment from it and pay the balance, if any, as long as the balance does not exceed our normal benefit.
  • When does coverage begin?
    New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received. We must receive the request to enroll newborns or adopted children within 31 days of the date of birth or adoption. On late enrollment requests, if adding the newborn/adopted child would have generated no additional premium at the time of the event, the effective date is the date of birth or adoption.
  • Will your plan send out detailed benefits information to employees?
    Five Points will provide the following standard communication materials to new members: Member ID cards Claim forms Summary plan descriptions Enrollment forms Member handbooks There may be a charge associated with certain materials.
  • What type of wellness or health promotion programs do you offer to your members?
    With our innovative health and wellness programs, we offer special health education, preventive care and wellness programs. These programs provide our members with resources - in conjunction with care and advice from their physician - that promote a healthy lifestyle and good health.
  • Does COBRA coverage count as creditable coverage?
    Yes, as defined in federal HIPAA legislation, COBRA coverage qualifies as creditable coverage.
  • Do I have to offer COBRA to terminating employees or their dependents?
    COBRA requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. The law covers group health plans maintained by employers with 20 or more employees in the prior year. It applies to plans in the private sector and those sponsored by state and local governments. Provisions of COBRA covering state and local government plans are administered by the Department of Health and Human Services. For additional information about COBRA requirement and other Department of Labor (DOL) regulations, refer to the Department of Labor website.
  • How does a new employer or insurance carrier know that an employee had prior group coverage?
    The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof.
  • How will the latest HIPAA requirements in the American Recovery and Reinvestment Act of 2009 affect the products your plan offers?
    The new HIPAA provisions in the American Recovery and Reinvestment Act of 2009 impose additional restrictions on the use and disclosure of personally-identifiable health information and increase the financial penalties for failure to comply with HIPAA regulations. There are also new requirements for notifying affected individuals about security breaches. We are making changes to our information technology systems, business policies and processes to comply with all of the new requirements. However, conforming to specific HIPAA requirements will not impact the products we offer, just how they are administered.
  • Who is subject to HIPAA regulations?
    HIPAA is directed at health insurance carriers and plan sponsors. Anyone covered under a full-risk health benefits plan issued by a carrier or covered under a self-insured health benefits plan offered by a plan sponsor, is subject to federal HIPAA.
  • What qualifies as creditable coverage?
    Creditable coverage, as defined under federal HIPAA, is considered as "creditable coverage" by Five Points, including: group health plan coverage (including a governmental or church plan), group or individual health insurance coverage, Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a state health benefits risk pool, the FEHBP, a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law; for example, dental-only coverage, or dental coverage that is provided in a separate policy or even in the same policy as medical, if such coverage is separately elected and results in additional premium.
  • How does an employer-imposed waiting period affect a break in coverage?
    An employer-imposed waiting period does not count in the consideration of whether or not an individual has a break in coverage.
  • What documentation is necessary for enrolling a group?
    Documentation requirements for enrolling groups of 2-50 lives (1 life, where required by state law) are regulated by state specific Small Group Reform regulations. Information regarding enrollment activities can be obtained by contacting the Five Points Health Benefits office. To enable a smooth transition into our Middle Market and National Account plans, the following implementation activities are recommended: Both parties have a mutual understanding of the plan design and effective date requested. Both parties meet to agree upon implementation responsibilities and schedules. Develop contact list for both parties. Discuss services in progress and the transition of claim history, if applicable. Determine dates, times and locations of any employee enrollment meetings. Copies of current plan booklet certificates provided to us. Determine how eligibility will be provided. If provided electronically, meet to establish layout of tape and possible programming issues. Determine appropriate enrollment materials to be provided to the employees. Develop special employee letters as needed. Test eligibility tape submitted by client if applicable. Client schedules enrollment meetings and communicates the transition to all personnel. Enrollment materials delivered to all client locations. Enrollment meetings are conducted by our enrollment team. Eligibility is provided to us at least two to three weeks before the effective date. Eligibility is fed into eligibility system and member ID cards are produced. ID cards are mailed to the plan members' homes within 10 to 12 business days. Client contracts and employee booklet-certificates of coverage are mailed to the client for distribution to employees. Our customer service personnel meet with client to discuss billing and ongoing maintenance of the plan. The process described above should take place at least two months prior to the effective date. If the client provides eligibility information electronically, one month's advance preparation is preferable.
  • Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
    A signature may be required upon renewal even if there are no changes other than the renewal rates. This provides confirmation from the employer that they are in agreement with the plan designs and corresponding rates, which become effective on their plan anniversary.
  • Is payment required at the time of application?
    Binder checks are requested at our discretion as a condition of sale for specific groups with more than 50 eligible employees. Groups with 50 employees, or less, require a binder check.
  • What percentage of premium does the employer have to contribute?
    We require the employer to contribute at least 50 percent of the total cost of the plan, or 75 percent of the cost of employee-only coverage. State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. These guidelines may vary by state and group size.
  • What are the enrollment deadlines for a new group?
    The enrollment deadline for a new small group [2-50 lives (1 life, where required by state law)] varies by state. Deadlines for your state can be obtained by contacting Five Points Health Benefits, LLC office. The time it takes to install a plan varies depending on the number of employees, plan design, customer's system capabilities, and development. Because each customer has individual needs, we are unable to exactly estimate the amount of full-time equivalent hours and lead time for the tasks. Ideally, we need 60 to 90 days to complete installation. This gives us time to process enrollment, generate and mail ID cards, set up plans in our systems, test systems, etc.
  • How do I submit enrollment files to the plan?
    Enrollment applications are utilized in the Small Group Segment [2-50 lives (1 life, where required by state law)]. They can be submitted via paper or fax to the appropriate Plan Sponsor Services unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents. Enrollment files for plans over 50 lives can be submitted via paper, tape or electronic media using one of our secure electronic file transfer processes. Submission of eligibility information by more than one location or via multiple methods will result in additional charges. Costs associated with any custom programming necessary to accept eligibility information are excluded from the initial rates and are billed separately. The customer's file must be IBM-compatible and must contain certain data in a specified format, including employee name, date of birth, Social Security number and covered dependent information. Middle Market and National Account customers can access EZLink--our Internet-based benefits and human resources (HR) administration solution. Customers can perform online eligibility, enrollment and account maintenance, as well as online billing and electronic funds transfer (EFT) for payment. EZLink also provides standard HR reports and other HR administration capabilities.
  • Can a group downgrade to a less expensive product at a time other than its normal renewal date?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a group upgrade medical at a time other than renewal if the group has grown?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a small group get lower rates if they do not use a broker?
    Rating considerations for broker commissions vary by product and by site.
  • Who must be notified of a change of address or other administrative change?
    The plan administrator or producer of record can notify the Plan Sponsor Services for a change of address; however, the account manager can be notified also.
  • How do I change the waiting/elimination/probationary period on a group's policy?
    Our local sales offices provide contact lists for administrative procedures. A request for a revision to the policy must be submitted through the assigned account manager.
  • Can I e-mail enrollment files to the plan?
    To protect members' privacy, enrollment files may be submitted via enrollment form or fax. E-mail enrollment data will only be accepted if the files are encrypted prior to transmission. Enrollment files for Small Group business must be submitted via paper or fax to the appropriate Plan Sponsor Services Unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.
  • What is the maximum waiting/elimination/probationary period a group can impose?
    We require that a probationary period be consistently applied within a class of employees. We may match the current carrier's probationary period; however, our standard maximum is six months.
  • What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?
    The average turnaround time for a small group [2-50 lives, (1 life, where required by state law)] is determined by the Five Points Benefit Plans, LLC. State and federal regulations determine how underwriting is applied to the group or the individual. For our Middle Market and National Account customers, underwriting would be applicable on a group basis. We work with each of our customers or their consultant to determine when they need renewal pricing completed. Depending on the complexity of the request, a renewal generally takes between one and three weeks to complete.
  • Describe your provider networks (e.g., types of networks for each product).
    Our accessibility standards utilize GeoAccess indicators for urban, suburban and rural zip codes. Where gaps are identified, we will work with the customer to formulate a potential solution for member coverage. Provider Search, our Internet provider directory provides a comprehensive listing of the providers in our networks. We add physicians to our networks upon request as long as they meet our participation criteria. However, when we review our networks for purposes of adequacy, we follow a distinctive set of guidelines to determine the configuration of each network. Based on population size, we focus on the service area and types of services of each target hospital and its affiliated physicians to see that acceptable levels of care are readily available for members of the managed care program. We have developed these guidelines so our networks give members reasonable access to essential and important medical services.
  • Do you provide a toll-free Member Services number for the retail and mail-order programs?
    Yes. Five Points provides a single, toll-free telephone number that members can call for both medical and pharmacy benefit questions. In addition, each mail-order vendor provides a toll-free customer service line for members to check the status of their orders, request prescription refills or speak with a pharmacist about their medications.
  • Does your program offer prospective, concurrent, or retrospective drug utilization review?
    Yes.
  • How can I tell if my Pharmacy Plan meets Creditable Coverage requirements?
    The Centers for Medicare and Medicaid Services (CMS) provide general information to employers about Medicare Part D Creditable Coverage requirements and model disclosure notices. See CMS information on creditable coverage >
  • Does a group or a subscriber within a group have to take prescription drug coverage?
    We offer multiple plan design options for our customers encompassing a variety of plan provisions. As a result, group contracts vary by customer. However, a plan administrator may opt to offer several different plans to provide choices for their members. If more than one option is available, members can select a benefits plan that includes or excludes prescription coverage. Once a member selects a plan, coverage is provided as a package.
  • How many retail networks do you offer nationally?
    We offer a single national pharmacy network that provides members with access to over 67,000 pharmacies located in 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. The network includes 82% of the independent and chain pharmacies on our secure member site or by calling Member Services at the toll-free phone number on your Member ID card.
  • How do members obtain covered prescription drugs via mail order?
    Plan members receive an enrollment kit that includes the order forms and envelopes they need to request covered prescription drugs via mail-order delivery (where mail-order is available). To order a drug, the member completes an enrollment form and submits the profile information (with the first order only) and the original prescription(s) in the pre-addressed envelope. The member must include a check for the appropriate copayment(s) or provide a credit card number. If a member needs a mail-order brochure and order form to submit for an initial supply of medication, they should call the toll-free Member Services number on their Member ID card. After the initial form has been submitted, members can either call in refills using a toll-free phone number or mail a refill request. Members can also order refills via the Internet by accessing their mail-order provider's website directly. Members who have CVS Caremark Mail Service Pharmacy as their mail-order pharmacy can order refills or check the status of their order online. Members can link to CVS Caremark Mail Service Pharmacy by logging on to Five Point's self-service secure member website. Members can also request refills by calling CVS Caremark Mail Service Pharmacy directly. Generally, orders will be delivered, postage paid, by U.S. mail or another carrier within 14 days if they are "clean" and do not require intervention.
  • Do you use a preferred drug list (also called a formulary) and are members limited to using these preferred drugs?
    Optum Rx uses a preferred drug list of effective and affordable drugs approved by the U.S. Food and Drug Administration. In selecting drugs for this list, Optum Rx focuses first on quality before considering cost. Many drugs on the preferred drug list are subject to rebate arrangements between Optum Rx and the manufacturer of those drugs. Formulary requirements vary depending on the prescription drug plan design. Prescription drug benefit plans with an open formulary cover all drugs, except contractually excluded drugs, with some plans requiring different copayments for generic, brand-name formulary and brand-name nonformulary drugs. Open formularies are available with Optum Rx PPO-based and indemnity pharmacy plans and HMO pharmacy plans, where filed and approved. In certain HMO service areas, plans are available with a closed formulary. Closed formulary plans do not cover a group of products listed in the Optum Rx Formulary Guide as Formulary Exclusions. A physician may request coverage for a drug on the Formulary Exclusions List by providing the Pharmacy Management Precertification Unit with clinical documentation supporting the drug's medical necessity. Contractually excluded drugs are not covered under closed formulary plans as well. To learn about Pharmacy Management's guidelines for determining health care coverage for selected outpatient prescription drugs on the Formulary Exclusions List or those drugs requiring precertification or step-therapy, see our Pharmacy Clinical Policy Bulletins.
  • When can I apply for a health plan?
    In general, you can only change or apply for health care coverage during the yearly open enrollment period (OEP).
  • How much is it going to cost me for a specific service or procedure?
    You can sign in to My Health Toolkit on the website. Under the Resource tab, there's a link to Find Care. Select Procedure Costs.
  • How do I find information on how Five Points paid my claim?
    You can call us at 915-803-4198.
  • Do I have benefits for telemedicine? If yes, what are the benefits and how does this process work?
    More info.
  • How do I request a review of a processed claim?
    Review and appeal information is on your EOB. You can access your EOBs through my Health Toolkit. You can also review claims and check claims through the portal. If you have more than one claim and need help understanding all the information, this is a good place to review all your claims at once.
  • What are our operating hours?
    Monday to Friday, 7AM to 5PM
  • How do I find doctors covered by my insurance?
    You can do this in a number of ways. You ca sign in to My Health Toolkit on the website. Under the Resources tab, there is a link for Find Care. There is a Find Care icon in the bottom right corner. In the members section of the website you can choose Find a Doctor online provider directories.
  • What do I need to consider when choosing a health plan?
    Health insurance works by helping you pay for medical care and services, so you don't have to pay all your health care costs on your own. The best health plan for you is one that meets your health care needs, budget, and expectations. But it can be tough to know what to look for - and what to avoid. Before you decide on a plan, you'll need to think about: Your health and how often you need care How much coverage you need How much money you're willing to spend How different health plans work What each plan offers beyond the basics Understanding your total health care costs is key to getting the most out of your plan and avoiding potentially expensive surprises.
  • What are my deductible and out-of-pocket amounts?
    When you log in to My Health Toolkit online or through the mobile app.
  • How do I obtain an ID Card or additional ID Cards?
    Review your member ID card information carefully and call us at 915-803-4198 or email us at alejandra@fivepointsmecplan.com if you have questions regarding your member ID card.
  • Can I upgrade my plan at any time?
    Absolutely! There is no wait time to upgrade your health plan. You can call us at 915.803.4198 or email us at alejandra@fivepointsmecplan.com, and we will be more than happy to assist you.
  • How do I add or remove dependents on my policy?
    More info.
  • What are the benefits for specific service or treatment?
    You can look up details about your coverage in My Health Toolkit.
  • Do you offer dental and vision?
    Coming Soon
  • How do you enroll?
    Please contact our office at 915.803.4198 and one of our agents will assist you with enrollment
  • What benefits do you receive?
    Coming soon
  • What is your "Provider Network"?
    First Health Network PPO with over 1 million providers nationwide
  • Who can become a Five Points Health Benefit member?
    Coming Soon
  • We can't switch until the end of our plan year, right?
    Coming Soon
  • Do all of my employees need to be in one of the listed states?
    Employees can be located anywhere in the U.S., there are no state restrictions on using your Five Points Health Benefit plan.
  • How many employees do you need to be a "company"?
    Two is the minimum to be a "company"
  • How can I check if my doctor is in-network?
    Use Five Points' First Health Provider Search tool to search our network of partners including a variety of modern and accessible providers who are available for almost everything.
  • How does Five Points save me money?
    Five Points negotiates pricing with providers according to objective, industry-accepted metrics. By reducing provider markups, premiums become more manageable. Five Points also provides level-funded plans, which allow you to receive a credit or refund if you do not spend what was budgeted in your premiums. Small businesses can deduct the cost of employee premiums from their federal tax filings. Depending on your situation, additional tax credits may be available.
  • What are the types of Individual and Family plans Five Points Benefit Plans offers?
    Coming Soon
  • What does Silver, Gold, and Platinum on the Individual and Family plans mean?
    Individual and Family plans are organized into 3 coverage levels and getting to know them will help you understand what you are responsible for paying and which plan will best fit your health care needs. It is important to understand that the metal tiers reflect a difference in cost. You receive our high quality Five Points service in all of our plans.
  • Can I purchase individual and family health plans at a lower cost?
    Healthcare costs can be overwhelming for many individuals and families. The Affordable Care Act (ACA) makes it easier for individuals to compare a variety of health insurance plans and select the one that best suits their needs and budget. The ACA also provides financial assistance (sometimes referred to as subsidies) to qualified individuals based on income. You can also compare plans, calculate your rate, and apply for health plans. Learn about Individual & Family health plan affordability by contacting us at 915-803-4198 or by email at alejandra@fivepointsmecplan.com to learn more.
  • When can I enroll?
    Open enrollment is 365 days a year.
  • Do you have to be a college student?
    No, you may be a student first grade and up.

For Individuals & Families

  • Pharmacy FAQs
    Pharmacy coverage >
  • Member resource FAQs
    Choosing a health care provider > Emergency care > Member benefits and services > Opioid coverage and resources > Personal Health Record >
  • How do I select or change a primary care provider (PCP)?
    You can change your PCP through your secure member account. If you would rather call us, use the number on your Five Points ID card.
  • Can I change my PCP any time I want?
    Yes. Not all plans require you to choose a PCP, but if your plan allows you to choose one, you can change it whenever you want.
  • What if my PCP leaves First Health's network?
    If your physician leaves First Health's network, you will be asked to select another PCP.
  • What if my current doctor doesn't take Five Point's health care coverage?
    Ask your doctor to contact our Member Services office at the toll-free number on your member ID card. One of our Member Services professionals will help your physician get in touch with the appropriate network management office.
  • How do I get a paper provider directory?
    Your employer's benefits office can give you a provider directory for your area.
  • How do I find a participating provider?
    Our online directory can help you find: Doctors (general and specialists) Hospitals and urgent care centers Mental health care Pharmacies Substance abuse treatment Physical therapists Dialysis centers Eye exam providers Medical equipment suppliers Hospice care Hearing discount locations Much more The simplest way to use our online directory is through your secure member account. Once you log in, you're identified by your plan type and the system can easily find providers near you that accept your insurance. You also can use our public directory. It will list all of the plans we offer, and ask you to choose yours. If you're not sure, you can search without choosing a plan by name. If you find a provider in the public directory, we encourage you to contact the provider's office before making an appointment, to confirm that they accept your plan. Use our public online provider directory >
  • What should I do in an emergency?
    If an emergency happens close to home: Call your local emergency hotline (911) or go to the nearest emergency facility. If possible, you should also call your primary care doctor. In all cases, you should contact your primary care doctor as soon as possible after receiving treatment. Once an emergency facility has stabilized your condition, their staff members should try to contact your primary care doctor. Your primary care doctor knows your medical history and is also responsible for coordinating your health care. Please note that all follow-up care should be coordinated through your primary care doctor. If an emergency happens when you're traveling away from home: Remember that urgently needed care is covered while you are traveling outside of your local Five Points service area. You should seek immediate treatment for any illness or injury that would be considered an emergency, or for the care of any urgent problem. If you are admitted to an inpatient facility, you should immediately notify your primary care doctor and Five Points. In other cases, you should notify your primary care doctor and Five Points within 48 hours of an emergency. When seeking emergency care, please note that: Any services you receive must be covered under the terms of your Five Points plan. You are responsible for any emergency room copay. An emergency room copay does not apply when you are admitted for an overnight hospital stay.
  • Do you cover emergency care?
    Yes, we cover emergency care. In fact, emergency care is covered 24 hours a day, seven days a week - anywhere in the world. Generally speaking, an emergency is a situation in which you could reasonably expect that the absence of immediate medical attention could result in serious jeopardy to your health, or if you are a pregnant woman, to the health of your unborn child. This definition may vary based on state regulations.
  • Where can I get a summary of my benefits?
    A summary of benefits and coverage (SBC) shows what your plan covers and your share of the costs. If you have insurance through your job, or your spouse's or partner's job, contact the employer's benefits office. They can give you a summary of benefits. You may be able to find your summary of benefits online.
  • How do I get help from Member Services?
    You have options to get the help you need. For personalized service Call the Member Services number on your ID card. Our representatives are ready to help you. For 24/7 self-service Use our website. The menu prompts will guide you.
  • How can I get a new ID card?
    Your member ID card is always available on your member website. When you log in, you can: Pull up your digital ID card. You can print it or email it. Your digital ID card is the same as your plastic ID card. Request a new ID card. We can send a new plastic ID card to your home.
  • How do I change my primary care physician (PCP)?
    There are two steps to change your PCP: Log in to your member website. You can search for a PCP by ZIP code, language spoken and other preferences. Call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I report a name or address change to my health plan?
    Keeping your name and address up to date with your health plan is important. Here's how to report a change: If you have a Five Points plan through your employer: Let your employer know your name or address has changed. Your employer will send this update to us. If you have a plan that you purchased directly from us (not through an employer): Call Member Services at the number on your ID card. If you have an exchange plan: If you purchased your plan on the Health Insurance Marketplace, contact the plan directly to update your name and address.
  • What happens if my PCP leaves the network?
    Rest assured - if your PCP is no longer in our network, we can help you find another care provider who's right for you. First, log in to choose another PCP who participates with us. We offer an expansive network of doctors to choose from. And you can search by ZIP code, language spoken and other preferences. Next, call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I add a family member to my health plan - or remove a family member?
    You can change your coverage, including adding or removing family members, during the annual Open Enrollment Period. To do so, you'll need to contact your employer. Had a big life even outside the Open Enrollment window? Typically, you can change your coverage within 30 to 60 days of: A marriage or divorce The death of your spouse or dependent The birth or adoption of a child The start or end of your spouse's employment A change from full-time to part-time employment for you or your spouse Unpaid leave of absence for you of your spouse Major change in your coverage, or your spouse's coverage (when caused by your spouse's employment)
  • If I leave my job, where can I find information about continuing my health insurance?
    First, contact your prior employer's benefits office. Let them know you're interested in buying a COBRA (Consolidated Omnibus Budget Reconciliation Act) policy. By federal law, companies with more than 20 employees need to make you aware of your options for buying this coverage.
  • How can I cover my newborn from birth?
    Congratulations to you. Your child is generally covered for 31 days from their date of birth. To continue coverage after this time, you'll need to enroll your child within those 31 days and pay the plan premium.
  • Managing employee benefits FAQs
    Claims Resources > Cobra Coverage and HIPAA guidance > Enrollments, renewals, and quoting > Notification of changes, eligibility and network > Pharmacy management >
  • What should my employee do if a claim is denied?
    Once a claim is denied, the right to appeal is set forth in the initial denial letter. To start the appeals process, the member or a duly authorized representative acting on behalf of the member submits an oral or written request asking for a change in the initial determination decision regarding claim payment, plan interpretation, benefit determination or eligibility. The member, or provider/representative acting on behalf of the member, has 180 days after receipt of a coverage decision to file an appeal, unless otherwise required by law. Within five business days of receipt of a written appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.
  • When traveling, can my employees receive coverage out of area?
    A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay for covered services. No prior authorization or referral is needed. For routine treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also visit a provider without a referral and receive a nonreferred benefit level subject to deductible and coinsurance. We cover emergency care at the preferred level.
  • When will my employees need to file a claim?
    Non-network or out-of-area services: The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our Explanation of Benefits (EOB). Traditional Choice: Members can access care through any licensed provider; there are no networks in this plan. The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our EOB.
  • I have an employee out on disability. How long am I required to keep him/her on the group health insurance policy?
    The length of extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible for COBRA coverage.
  • How are claims handled for employees with more than one health insurance plan?
    Our COB approach is "pursue, then pay." We investigate the availability of other primary benefits before issuing benefits. When other coverage information is obtained, we flag the online family eligibility record. The claim system will then automatically present a COB flag during claim processing. The notice includes details about the other coverage, which family members the other plan covers, the carrier, type of coverage (e.g., medical only, medical-dental, etc.) and date of the last update. When a claim is submitted, if we are secondary and the primary carrier's Explanation of Benefits (EOB) is not attached to the claim, the claim is pended for receipt of the primary carrier's EOB. Upon receipt of the primary carrier's EOB, claims are processed as follows: For maintenance of benefits (MOB) or non-duplication plans, the COB allowable expense is our normal benefit (i.e., our negotiated rate reduced by copays, coinsurance, or other applicable plan provisions). For standard plans, the COB allowable expense is the lesser of the primary plan's negotiated fee (if the primary plan is also a network plan) or the amount submitted to the primary carrier, subject to R&C limitations. Once we determine the allowable expense, we subtract the primary carrier's payment from it and pay the balance, if any, as long as the balance does not exceed our normal benefit.
  • When does coverage begin?
    New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received. We must receive the request to enroll newborns or adopted children within 31 days of the date of birth or adoption. On late enrollment requests, if adding the newborn/adopted child would have generated no additional premium at the time of the event, the effective date is the date of birth or adoption.
  • Will your plan send out detailed benefits information to employees?
    Five Points will provide the following standard communication materials to new members: Member ID cards Claim forms Summary plan descriptions Enrollment forms Member handbooks There may be a charge associated with certain materials.
  • What type of wellness or health promotion programs do you offer to your members?
    With our innovative health and wellness programs, we offer special health education, preventive care and wellness programs. These programs provide our members with resources - in conjunction with care and advice from their physician - that promote a healthy lifestyle and good health.
  • Does COBRA coverage count as creditable coverage?
    Yes, as defined in federal HIPAA legislation, COBRA coverage qualifies as creditable coverage.
  • Do I have to offer COBRA to terminating employees or their dependents?
    COBRA requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. The law covers group health plans maintained by employers with 20 or more employees in the prior year. It applies to plans in the private sector and those sponsored by state and local governments. Provisions of COBRA covering state and local government plans are administered by the Department of Health and Human Services. For additional information about COBRA requirement and other Department of Labor (DOL) regulations, refer to the Department of Labor website.
  • How does a new employer or insurance carrier know that an employee had prior group coverage?
    The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof.
  • How will the latest HIPAA requirements in the American Recovery and Reinvestment Act of 2009 affect the products your plan offers?
    The new HIPAA provisions in the American Recovery and Reinvestment Act of 2009 impose additional restrictions on the use and disclosure of personally-identifiable health information and increase the financial penalties for failure to comply with HIPAA regulations. There are also new requirements for notifying affected individuals about security breaches. We are making changes to our information technology systems, business policies and processes to comply with all of the new requirements. However, conforming to specific HIPAA requirements will not impact the products we offer, just how they are administered.
  • Who is subject to HIPAA regulations?
    HIPAA is directed at health insurance carriers and plan sponsors. Anyone covered under a full-risk health benefits plan issued by a carrier or covered under a self-insured health benefits plan offered by a plan sponsor, is subject to federal HIPAA.
  • What qualifies as creditable coverage?
    Creditable coverage, as defined under federal HIPAA, is considered as "creditable coverage" by Five Points, including: group health plan coverage (including a governmental or church plan), group or individual health insurance coverage, Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a state health benefits risk pool, the FEHBP, a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law; for example, dental-only coverage, or dental coverage that is provided in a separate policy or even in the same policy as medical, if such coverage is separately elected and results in additional premium.
  • How does an employer-imposed waiting period affect a break in coverage?
    An employer-imposed waiting period does not count in the consideration of whether or not an individual has a break in coverage.
  • What documentation is necessary for enrolling a group?
    Documentation requirements for enrolling groups of 2-50 lives (1 life, where required by state law) are regulated by state specific Small Group Reform regulations. Information regarding enrollment activities can be obtained by contacting the Five Points Health Benefits office. To enable a smooth transition into our Middle Market and National Account plans, the following implementation activities are recommended: Both parties have a mutual understanding of the plan design and effective date requested. Both parties meet to agree upon implementation responsibilities and schedules. Develop contact list for both parties. Discuss services in progress and the transition of claim history, if applicable. Determine dates, times and locations of any employee enrollment meetings. Copies of current plan booklet certificates provided to us. Determine how eligibility will be provided. If provided electronically, meet to establish layout of tape and possible programming issues. Determine appropriate enrollment materials to be provided to the employees. Develop special employee letters as needed. Test eligibility tape submitted by client if applicable. Client schedules enrollment meetings and communicates the transition to all personnel. Enrollment materials delivered to all client locations. Enrollment meetings are conducted by our enrollment team. Eligibility is provided to us at least two to three weeks before the effective date. Eligibility is fed into eligibility system and member ID cards are produced. ID cards are mailed to the plan members' homes within 10 to 12 business days. Client contracts and employee booklet-certificates of coverage are mailed to the client for distribution to employees. Our customer service personnel meet with client to discuss billing and ongoing maintenance of the plan. The process described above should take place at least two months prior to the effective date. If the client provides eligibility information electronically, one month's advance preparation is preferable.
  • Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
    A signature may be required upon renewal even if there are no changes other than the renewal rates. This provides confirmation from the employer that they are in agreement with the plan designs and corresponding rates, which become effective on their plan anniversary.
  • Is payment required at the time of application?
    Binder checks are requested at our discretion as a condition of sale for specific groups with more than 50 eligible employees. Groups with 50 employees, or less, require a binder check.
  • What percentage of premium does the employer have to contribute?
    We require the employer to contribute at least 50 percent of the total cost of the plan, or 75 percent of the cost of employee-only coverage. State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. These guidelines may vary by state and group size.
  • What are the enrollment deadlines for a new group?
    The enrollment deadline for a new small group [2-50 lives (1 life, where required by state law)] varies by state. Deadlines for your state can be obtained by contacting Five Points Health Benefits, LLC office. The time it takes to install a plan varies depending on the number of employees, plan design, customer's system capabilities, and development. Because each customer has individual needs, we are unable to exactly estimate the amount of full-time equivalent hours and lead time for the tasks. Ideally, we need 60 to 90 days to complete installation. This gives us time to process enrollment, generate and mail ID cards, set up plans in our systems, test systems, etc.
  • How do I submit enrollment files to the plan?
    Enrollment applications are utilized in the Small Group Segment [2-50 lives (1 life, where required by state law)]. They can be submitted via paper or fax to the appropriate Plan Sponsor Services unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents. Enrollment files for plans over 50 lives can be submitted via paper, tape or electronic media using one of our secure electronic file transfer processes. Submission of eligibility information by more than one location or via multiple methods will result in additional charges. Costs associated with any custom programming necessary to accept eligibility information are excluded from the initial rates and are billed separately. The customer's file must be IBM-compatible and must contain certain data in a specified format, including employee name, date of birth, Social Security number and covered dependent information. Middle Market and National Account customers can access EZLink--our Internet-based benefits and human resources (HR) administration solution. Customers can perform online eligibility, enrollment and account maintenance, as well as online billing and electronic funds transfer (EFT) for payment. EZLink also provides standard HR reports and other HR administration capabilities.
  • Can a group downgrade to a less expensive product at a time other than its normal renewal date?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a group upgrade medical at a time other than renewal if the group has grown?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a small group get lower rates if they do not use a broker?
    Rating considerations for broker commissions vary by product and by site.
  • Who must be notified of a change of address or other administrative change?
    The plan administrator or producer of record can notify the Plan Sponsor Services for a change of address; however, the account manager can be notified also.
  • How do I change the waiting/elimination/probationary period on a group's policy?
    Our local sales offices provide contact lists for administrative procedures. A request for a revision to the policy must be submitted through the assigned account manager.
  • Can I e-mail enrollment files to the plan?
    To protect members' privacy, enrollment files may be submitted via enrollment form or fax. E-mail enrollment data will only be accepted if the files are encrypted prior to transmission. Enrollment files for Small Group business must be submitted via paper or fax to the appropriate Plan Sponsor Services Unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.
  • What is the maximum waiting/elimination/probationary period a group can impose?
    We require that a probationary period be consistently applied within a class of employees. We may match the current carrier's probationary period; however, our standard maximum is six months.
  • What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?
    The average turnaround time for a small group [2-50 lives, (1 life, where required by state law)] is determined by the Five Points Benefit Plans, LLC. State and federal regulations determine how underwriting is applied to the group or the individual. For our Middle Market and National Account customers, underwriting would be applicable on a group basis. We work with each of our customers or their consultant to determine when they need renewal pricing completed. Depending on the complexity of the request, a renewal generally takes between one and three weeks to complete.
  • Describe your provider networks (e.g., types of networks for each product).
    Our accessibility standards utilize GeoAccess indicators for urban, suburban and rural zip codes. Where gaps are identified, we will work with the customer to formulate a potential solution for member coverage. Provider Search, our Internet provider directory provides a comprehensive listing of the providers in our networks. We add physicians to our networks upon request as long as they meet our participation criteria. However, when we review our networks for purposes of adequacy, we follow a distinctive set of guidelines to determine the configuration of each network. Based on population size, we focus on the service area and types of services of each target hospital and its affiliated physicians to see that acceptable levels of care are readily available for members of the managed care program. We have developed these guidelines so our networks give members reasonable access to essential and important medical services.
  • Do you provide a toll-free Member Services number for the retail and mail-order programs?
    Yes. Five Points provides a single, toll-free telephone number that members can call for both medical and pharmacy benefit questions. In addition, each mail-order vendor provides a toll-free customer service line for members to check the status of their orders, request prescription refills or speak with a pharmacist about their medications.
  • Does your program offer prospective, concurrent, or retrospective drug utilization review?
    Yes.
  • How can I tell if my Pharmacy Plan meets Creditable Coverage requirements?
    The Centers for Medicare and Medicaid Services (CMS) provide general information to employers about Medicare Part D Creditable Coverage requirements and model disclosure notices. See CMS information on creditable coverage >
  • Does a group or a subscriber within a group have to take prescription drug coverage?
    We offer multiple plan design options for our customers encompassing a variety of plan provisions. As a result, group contracts vary by customer. However, a plan administrator may opt to offer several different plans to provide choices for their members. If more than one option is available, members can select a benefits plan that includes or excludes prescription coverage. Once a member selects a plan, coverage is provided as a package.
  • How many retail networks do you offer nationally?
    We offer a single national pharmacy network that provides members with access to over 67,000 pharmacies located in 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. The network includes 82% of the independent and chain pharmacies on our secure member site or by calling Member Services at the toll-free phone number on your Member ID card.
  • How do members obtain covered prescription drugs via mail order?
    Plan members receive an enrollment kit that includes the order forms and envelopes they need to request covered prescription drugs via mail-order delivery (where mail-order is available). To order a drug, the member completes an enrollment form and submits the profile information (with the first order only) and the original prescription(s) in the pre-addressed envelope. The member must include a check for the appropriate copayment(s) or provide a credit card number. If a member needs a mail-order brochure and order form to submit for an initial supply of medication, they should call the toll-free Member Services number on their Member ID card. After the initial form has been submitted, members can either call in refills using a toll-free phone number or mail a refill request. Members can also order refills via the Internet by accessing their mail-order provider's website directly. Members who have CVS Caremark Mail Service Pharmacy as their mail-order pharmacy can order refills or check the status of their order online. Members can link to CVS Caremark Mail Service Pharmacy by logging on to Five Point's self-service secure member website. Members can also request refills by calling CVS Caremark Mail Service Pharmacy directly. Generally, orders will be delivered, postage paid, by U.S. mail or another carrier within 14 days if they are "clean" and do not require intervention.
  • Do you use a preferred drug list (also called a formulary) and are members limited to using these preferred drugs?
    Optum Rx uses a preferred drug list of effective and affordable drugs approved by the U.S. Food and Drug Administration. In selecting drugs for this list, Optum Rx focuses first on quality before considering cost. Many drugs on the preferred drug list are subject to rebate arrangements between Optum Rx and the manufacturer of those drugs. Formulary requirements vary depending on the prescription drug plan design. Prescription drug benefit plans with an open formulary cover all drugs, except contractually excluded drugs, with some plans requiring different copayments for generic, brand-name formulary and brand-name nonformulary drugs. Open formularies are available with Optum Rx PPO-based and indemnity pharmacy plans and HMO pharmacy plans, where filed and approved. In certain HMO service areas, plans are available with a closed formulary. Closed formulary plans do not cover a group of products listed in the Optum Rx Formulary Guide as Formulary Exclusions. A physician may request coverage for a drug on the Formulary Exclusions List by providing the Pharmacy Management Precertification Unit with clinical documentation supporting the drug's medical necessity. Contractually excluded drugs are not covered under closed formulary plans as well. To learn about Pharmacy Management's guidelines for determining health care coverage for selected outpatient prescription drugs on the Formulary Exclusions List or those drugs requiring precertification or step-therapy, see our Pharmacy Clinical Policy Bulletins.
  • When can I apply for a health plan?
    In general, you can only change or apply for health care coverage during the yearly open enrollment period (OEP).
  • How much is it going to cost me for a specific service or procedure?
    You can sign in to My Health Toolkit on the website. Under the Resource tab, there's a link to Find Care. Select Procedure Costs.
  • How do I find information on how Five Points paid my claim?
    You can call us at 915-803-4198.
  • Do I have benefits for telemedicine? If yes, what are the benefits and how does this process work?
    More info.
  • How do I request a review of a processed claim?
    Review and appeal information is on your EOB. You can access your EOBs through my Health Toolkit. You can also review claims and check claims through the portal. If you have more than one claim and need help understanding all the information, this is a good place to review all your claims at once.
  • What are our operating hours?
    Monday to Friday, 7AM to 5PM
  • How do I find doctors covered by my insurance?
    You can do this in a number of ways. You ca sign in to My Health Toolkit on the website. Under the Resources tab, there is a link for Find Care. There is a Find Care icon in the bottom right corner. In the members section of the website you can choose Find a Doctor online provider directories.
  • What do I need to consider when choosing a health plan?
    Health insurance works by helping you pay for medical care and services, so you don't have to pay all your health care costs on your own. The best health plan for you is one that meets your health care needs, budget, and expectations. But it can be tough to know what to look for - and what to avoid. Before you decide on a plan, you'll need to think about: Your health and how often you need care How much coverage you need How much money you're willing to spend How different health plans work What each plan offers beyond the basics Understanding your total health care costs is key to getting the most out of your plan and avoiding potentially expensive surprises.
  • What are my deductible and out-of-pocket amounts?
    When you log in to My Health Toolkit online or through the mobile app.
  • How do I obtain an ID Card or additional ID Cards?
    Review your member ID card information carefully and call us at 915-803-4198 or email us at alejandra@fivepointsmecplan.com if you have questions regarding your member ID card.
  • Can I upgrade my plan at any time?
    Absolutely! There is no wait time to upgrade your health plan. You can call us at 915.803.4198 or email us at alejandra@fivepointsmecplan.com, and we will be more than happy to assist you.
  • How do I add or remove dependents on my policy?
    More info.
  • What are the benefits for specific service or treatment?
    You can look up details about your coverage in My Health Toolkit.
  • Do you offer dental and vision?
    Coming Soon
  • How do you enroll?
    Please contact our office at 915.803.4198 and one of our agents will assist you with enrollment
  • What benefits do you receive?
    Coming soon
  • What is your "Provider Network"?
    First Health Network PPO with over 1 million providers nationwide
  • Who can become a Five Points Health Benefit member?
    Coming Soon
  • We can't switch until the end of our plan year, right?
    Coming Soon
  • Do all of my employees need to be in one of the listed states?
    Employees can be located anywhere in the U.S., there are no state restrictions on using your Five Points Health Benefit plan.
  • How many employees do you need to be a "company"?
    Two is the minimum to be a "company"
  • How can I check if my doctor is in-network?
    Use Five Points' First Health Provider Search tool to search our network of partners including a variety of modern and accessible providers who are available for almost everything.
  • How does Five Points save me money?
    Five Points negotiates pricing with providers according to objective, industry-accepted metrics. By reducing provider markups, premiums become more manageable. Five Points also provides level-funded plans, which allow you to receive a credit or refund if you do not spend what was budgeted in your premiums. Small businesses can deduct the cost of employee premiums from their federal tax filings. Depending on your situation, additional tax credits may be available.
  • What are the types of Individual and Family plans Five Points Benefit Plans offers?
    Coming Soon
  • What does Silver, Gold, and Platinum on the Individual and Family plans mean?
    Individual and Family plans are organized into 3 coverage levels and getting to know them will help you understand what you are responsible for paying and which plan will best fit your health care needs. It is important to understand that the metal tiers reflect a difference in cost. You receive our high quality Five Points service in all of our plans.
  • Can I purchase individual and family health plans at a lower cost?
    Healthcare costs can be overwhelming for many individuals and families. The Affordable Care Act (ACA) makes it easier for individuals to compare a variety of health insurance plans and select the one that best suits their needs and budget. The ACA also provides financial assistance (sometimes referred to as subsidies) to qualified individuals based on income. You can also compare plans, calculate your rate, and apply for health plans. Learn about Individual & Family health plan affordability by contacting us at 915-803-4198 or by email at alejandra@fivepointsmecplan.com to learn more.
  • When can I enroll?
    Open enrollment is 365 days a year.
  • Do you have to be a college student?
    No, you may be a student first grade and up.

For Students

  • Pharmacy FAQs
    Pharmacy coverage >
  • Member resource FAQs
    Choosing a health care provider > Emergency care > Member benefits and services > Opioid coverage and resources > Personal Health Record >
  • How do I select or change a primary care provider (PCP)?
    You can change your PCP through your secure member account. If you would rather call us, use the number on your Five Points ID card.
  • Can I change my PCP any time I want?
    Yes. Not all plans require you to choose a PCP, but if your plan allows you to choose one, you can change it whenever you want.
  • What if my PCP leaves First Health's network?
    If your physician leaves First Health's network, you will be asked to select another PCP.
  • What if my current doctor doesn't take Five Point's health care coverage?
    Ask your doctor to contact our Member Services office at the toll-free number on your member ID card. One of our Member Services professionals will help your physician get in touch with the appropriate network management office.
  • How do I get a paper provider directory?
    Your employer's benefits office can give you a provider directory for your area.
  • How do I find a participating provider?
    Our online directory can help you find: Doctors (general and specialists) Hospitals and urgent care centers Mental health care Pharmacies Substance abuse treatment Physical therapists Dialysis centers Eye exam providers Medical equipment suppliers Hospice care Hearing discount locations Much more The simplest way to use our online directory is through your secure member account. Once you log in, you're identified by your plan type and the system can easily find providers near you that accept your insurance. You also can use our public directory. It will list all of the plans we offer, and ask you to choose yours. If you're not sure, you can search without choosing a plan by name. If you find a provider in the public directory, we encourage you to contact the provider's office before making an appointment, to confirm that they accept your plan. Use our public online provider directory >
  • What should I do in an emergency?
    If an emergency happens close to home: Call your local emergency hotline (911) or go to the nearest emergency facility. If possible, you should also call your primary care doctor. In all cases, you should contact your primary care doctor as soon as possible after receiving treatment. Once an emergency facility has stabilized your condition, their staff members should try to contact your primary care doctor. Your primary care doctor knows your medical history and is also responsible for coordinating your health care. Please note that all follow-up care should be coordinated through your primary care doctor. If an emergency happens when you're traveling away from home: Remember that urgently needed care is covered while you are traveling outside of your local Five Points service area. You should seek immediate treatment for any illness or injury that would be considered an emergency, or for the care of any urgent problem. If you are admitted to an inpatient facility, you should immediately notify your primary care doctor and Five Points. In other cases, you should notify your primary care doctor and Five Points within 48 hours of an emergency. When seeking emergency care, please note that: Any services you receive must be covered under the terms of your Five Points plan. You are responsible for any emergency room copay. An emergency room copay does not apply when you are admitted for an overnight hospital stay.
  • Do you cover emergency care?
    Yes, we cover emergency care. In fact, emergency care is covered 24 hours a day, seven days a week - anywhere in the world. Generally speaking, an emergency is a situation in which you could reasonably expect that the absence of immediate medical attention could result in serious jeopardy to your health, or if you are a pregnant woman, to the health of your unborn child. This definition may vary based on state regulations.
  • Where can I get a summary of my benefits?
    A summary of benefits and coverage (SBC) shows what your plan covers and your share of the costs. If you have insurance through your job, or your spouse's or partner's job, contact the employer's benefits office. They can give you a summary of benefits. You may be able to find your summary of benefits online.
  • How do I get help from Member Services?
    You have options to get the help you need. For personalized service Call the Member Services number on your ID card. Our representatives are ready to help you. For 24/7 self-service Use our website. The menu prompts will guide you.
  • How can I get a new ID card?
    Your member ID card is always available on your member website. When you log in, you can: Pull up your digital ID card. You can print it or email it. Your digital ID card is the same as your plastic ID card. Request a new ID card. We can send a new plastic ID card to your home.
  • How do I change my primary care physician (PCP)?
    There are two steps to change your PCP: Log in to your member website. You can search for a PCP by ZIP code, language spoken and other preferences. Call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I report a name or address change to my health plan?
    Keeping your name and address up to date with your health plan is important. Here's how to report a change: If you have a Five Points plan through your employer: Let your employer know your name or address has changed. Your employer will send this update to us. If you have a plan that you purchased directly from us (not through an employer): Call Member Services at the number on your ID card. If you have an exchange plan: If you purchased your plan on the Health Insurance Marketplace, contact the plan directly to update your name and address.
  • What happens if my PCP leaves the network?
    Rest assured - if your PCP is no longer in our network, we can help you find another care provider who's right for you. First, log in to choose another PCP who participates with us. We offer an expansive network of doctors to choose from. And you can search by ZIP code, language spoken and other preferences. Next, call the toll-free Member Services number on your ID card. We can change your PCP for you or help you choose one that's right for you.
  • How do I add a family member to my health plan - or remove a family member?
    You can change your coverage, including adding or removing family members, during the annual Open Enrollment Period. To do so, you'll need to contact your employer. Had a big life even outside the Open Enrollment window? Typically, you can change your coverage within 30 to 60 days of: A marriage or divorce The death of your spouse or dependent The birth or adoption of a child The start or end of your spouse's employment A change from full-time to part-time employment for you or your spouse Unpaid leave of absence for you of your spouse Major change in your coverage, or your spouse's coverage (when caused by your spouse's employment)
  • If I leave my job, where can I find information about continuing my health insurance?
    First, contact your prior employer's benefits office. Let them know you're interested in buying a COBRA (Consolidated Omnibus Budget Reconciliation Act) policy. By federal law, companies with more than 20 employees need to make you aware of your options for buying this coverage.
  • How can I cover my newborn from birth?
    Congratulations to you. Your child is generally covered for 31 days from their date of birth. To continue coverage after this time, you'll need to enroll your child within those 31 days and pay the plan premium.
  • Managing employee benefits FAQs
    Claims Resources > Cobra Coverage and HIPAA guidance > Enrollments, renewals, and quoting > Notification of changes, eligibility and network > Pharmacy management >
  • What should my employee do if a claim is denied?
    Once a claim is denied, the right to appeal is set forth in the initial denial letter. To start the appeals process, the member or a duly authorized representative acting on behalf of the member submits an oral or written request asking for a change in the initial determination decision regarding claim payment, plan interpretation, benefit determination or eligibility. The member, or provider/representative acting on behalf of the member, has 180 days after receipt of a coverage decision to file an appeal, unless otherwise required by law. Within five business days of receipt of a written appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.
  • When traveling, can my employees receive coverage out of area?
    A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay for covered services. No prior authorization or referral is needed. For routine treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also visit a provider without a referral and receive a nonreferred benefit level subject to deductible and coinsurance. We cover emergency care at the preferred level.
  • When will my employees need to file a claim?
    Non-network or out-of-area services: The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our Explanation of Benefits (EOB). Traditional Choice: Members can access care through any licensed provider; there are no networks in this plan. The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our EOB.
  • I have an employee out on disability. How long am I required to keep him/her on the group health insurance policy?
    The length of extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible for COBRA coverage.
  • How are claims handled for employees with more than one health insurance plan?
    Our COB approach is "pursue, then pay." We investigate the availability of other primary benefits before issuing benefits. When other coverage information is obtained, we flag the online family eligibility record. The claim system will then automatically present a COB flag during claim processing. The notice includes details about the other coverage, which family members the other plan covers, the carrier, type of coverage (e.g., medical only, medical-dental, etc.) and date of the last update. When a claim is submitted, if we are secondary and the primary carrier's Explanation of Benefits (EOB) is not attached to the claim, the claim is pended for receipt of the primary carrier's EOB. Upon receipt of the primary carrier's EOB, claims are processed as follows: For maintenance of benefits (MOB) or non-duplication plans, the COB allowable expense is our normal benefit (i.e., our negotiated rate reduced by copays, coinsurance, or other applicable plan provisions). For standard plans, the COB allowable expense is the lesser of the primary plan's negotiated fee (if the primary plan is also a network plan) or the amount submitted to the primary carrier, subject to R&C limitations. Once we determine the allowable expense, we subtract the primary carrier's payment from it and pay the balance, if any, as long as the balance does not exceed our normal benefit.
  • When does coverage begin?
    New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received. We must receive the request to enroll newborns or adopted children within 31 days of the date of birth or adoption. On late enrollment requests, if adding the newborn/adopted child would have generated no additional premium at the time of the event, the effective date is the date of birth or adoption.
  • Will your plan send out detailed benefits information to employees?
    Five Points will provide the following standard communication materials to new members: Member ID cards Claim forms Summary plan descriptions Enrollment forms Member handbooks There may be a charge associated with certain materials.
  • What type of wellness or health promotion programs do you offer to your members?
    With our innovative health and wellness programs, we offer special health education, preventive care and wellness programs. These programs provide our members with resources - in conjunction with care and advice from their physician - that promote a healthy lifestyle and good health.
  • Does COBRA coverage count as creditable coverage?
    Yes, as defined in federal HIPAA legislation, COBRA coverage qualifies as creditable coverage.
  • Do I have to offer COBRA to terminating employees or their dependents?
    COBRA requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. The law covers group health plans maintained by employers with 20 or more employees in the prior year. It applies to plans in the private sector and those sponsored by state and local governments. Provisions of COBRA covering state and local government plans are administered by the Department of Health and Human Services. For additional information about COBRA requirement and other Department of Labor (DOL) regulations, refer to the Department of Labor website.
  • How does a new employer or insurance carrier know that an employee had prior group coverage?
    The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof.
  • How will the latest HIPAA requirements in the American Recovery and Reinvestment Act of 2009 affect the products your plan offers?
    The new HIPAA provisions in the American Recovery and Reinvestment Act of 2009 impose additional restrictions on the use and disclosure of personally-identifiable health information and increase the financial penalties for failure to comply with HIPAA regulations. There are also new requirements for notifying affected individuals about security breaches. We are making changes to our information technology systems, business policies and processes to comply with all of the new requirements. However, conforming to specific HIPAA requirements will not impact the products we offer, just how they are administered.
  • Who is subject to HIPAA regulations?
    HIPAA is directed at health insurance carriers and plan sponsors. Anyone covered under a full-risk health benefits plan issued by a carrier or covered under a self-insured health benefits plan offered by a plan sponsor, is subject to federal HIPAA.
  • What qualifies as creditable coverage?
    Creditable coverage, as defined under federal HIPAA, is considered as "creditable coverage" by Five Points, including: group health plan coverage (including a governmental or church plan), group or individual health insurance coverage, Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a state health benefits risk pool, the FEHBP, a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law; for example, dental-only coverage, or dental coverage that is provided in a separate policy or even in the same policy as medical, if such coverage is separately elected and results in additional premium.
  • How does an employer-imposed waiting period affect a break in coverage?
    An employer-imposed waiting period does not count in the consideration of whether or not an individual has a break in coverage.
  • What documentation is necessary for enrolling a group?
    Documentation requirements for enrolling groups of 2-50 lives (1 life, where required by state law) are regulated by state specific Small Group Reform regulations. Information regarding enrollment activities can be obtained by contacting the Five Points Health Benefits office. To enable a smooth transition into our Middle Market and National Account plans, the following implementation activities are recommended: Both parties have a mutual understanding of the plan design and effective date requested. Both parties meet to agree upon implementation responsibilities and schedules. Develop contact list for both parties. Discuss services in progress and the transition of claim history, if applicable. Determine dates, times and locations of any employee enrollment meetings. Copies of current plan booklet certificates provided to us. Determine how eligibility will be provided. If provided electronically, meet to establish layout of tape and possible programming issues. Determine appropriate enrollment materials to be provided to the employees. Develop special employee letters as needed. Test eligibility tape submitted by client if applicable. Client schedules enrollment meetings and communicates the transition to all personnel. Enrollment materials delivered to all client locations. Enrollment meetings are conducted by our enrollment team. Eligibility is provided to us at least two to three weeks before the effective date. Eligibility is fed into eligibility system and member ID cards are produced. ID cards are mailed to the plan members' homes within 10 to 12 business days. Client contracts and employee booklet-certificates of coverage are mailed to the client for distribution to employees. Our customer service personnel meet with client to discuss billing and ongoing maintenance of the plan. The process described above should take place at least two months prior to the effective date. If the client provides eligibility information electronically, one month's advance preparation is preferable.
  • Does the renewal paperwork require signatures from the broker and/or the group, if there are no changes other than the renewal rates?
    A signature may be required upon renewal even if there are no changes other than the renewal rates. This provides confirmation from the employer that they are in agreement with the plan designs and corresponding rates, which become effective on their plan anniversary.
  • Is payment required at the time of application?
    Binder checks are requested at our discretion as a condition of sale for specific groups with more than 50 eligible employees. Groups with 50 employees, or less, require a binder check.
  • What percentage of premium does the employer have to contribute?
    We require the employer to contribute at least 50 percent of the total cost of the plan, or 75 percent of the cost of employee-only coverage. State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. These guidelines may vary by state and group size.
  • What are the enrollment deadlines for a new group?
    The enrollment deadline for a new small group [2-50 lives (1 life, where required by state law)] varies by state. Deadlines for your state can be obtained by contacting Five Points Health Benefits, LLC office. The time it takes to install a plan varies depending on the number of employees, plan design, customer's system capabilities, and development. Because each customer has individual needs, we are unable to exactly estimate the amount of full-time equivalent hours and lead time for the tasks. Ideally, we need 60 to 90 days to complete installation. This gives us time to process enrollment, generate and mail ID cards, set up plans in our systems, test systems, etc.
  • How do I submit enrollment files to the plan?
    Enrollment applications are utilized in the Small Group Segment [2-50 lives (1 life, where required by state law)]. They can be submitted via paper or fax to the appropriate Plan Sponsor Services unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents. Enrollment files for plans over 50 lives can be submitted via paper, tape or electronic media using one of our secure electronic file transfer processes. Submission of eligibility information by more than one location or via multiple methods will result in additional charges. Costs associated with any custom programming necessary to accept eligibility information are excluded from the initial rates and are billed separately. The customer's file must be IBM-compatible and must contain certain data in a specified format, including employee name, date of birth, Social Security number and covered dependent information. Middle Market and National Account customers can access EZLink--our Internet-based benefits and human resources (HR) administration solution. Customers can perform online eligibility, enrollment and account maintenance, as well as online billing and electronic funds transfer (EFT) for payment. EZLink also provides standard HR reports and other HR administration capabilities.
  • Can a group downgrade to a less expensive product at a time other than its normal renewal date?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a group upgrade medical at a time other than renewal if the group has grown?
    The standard time for plan revisions is the renewal date or within 31 days after the renewal date. Midyear plan revisions may be considered, but require Financial Underwriting approval for the exception.
  • Can a small group get lower rates if they do not use a broker?
    Rating considerations for broker commissions vary by product and by site.
  • Who must be notified of a change of address or other administrative change?
    The plan administrator or producer of record can notify the Plan Sponsor Services for a change of address; however, the account manager can be notified also.
  • How do I change the waiting/elimination/probationary period on a group's policy?
    Our local sales offices provide contact lists for administrative procedures. A request for a revision to the policy must be submitted through the assigned account manager.
  • Can I e-mail enrollment files to the plan?
    To protect members' privacy, enrollment files may be submitted via enrollment form or fax. E-mail enrollment data will only be accepted if the files are encrypted prior to transmission. Enrollment files for Small Group business must be submitted via paper or fax to the appropriate Plan Sponsor Services Unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.
  • What is the maximum waiting/elimination/probationary period a group can impose?
    We require that a probationary period be consistently applied within a class of employees. We may match the current carrier's probationary period; however, our standard maximum is six months.
  • What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status?
    The average turnaround time for a small group [2-50 lives, (1 life, where required by state law)] is determined by the Five Points Benefit Plans, LLC. State and federal regulations determine how underwriting is applied to the group or the individual. For our Middle Market and National Account customers, underwriting would be applicable on a group basis. We work with each of our customers or their consultant to determine when they need renewal pricing completed. Depending on the complexity of the request, a renewal generally takes between one and three weeks to complete.
  • Describe your provider networks (e.g., types of networks for each product).
    Our accessibility standards utilize GeoAccess indicators for urban, suburban and rural zip codes. Where gaps are identified, we will work with the customer to formulate a potential solution for member coverage. Provider Search, our Internet provider directory provides a comprehensive listing of the providers in our networks. We add physicians to our networks upon request as long as they meet our participation criteria. However, when we review our networks for purposes of adequacy, we follow a distinctive set of guidelines to determine the configuration of each network. Based on population size, we focus on the service area and types of services of each target hospital and its affiliated physicians to see that acceptable levels of care are readily available for members of the managed care program. We have developed these guidelines so our networks give members reasonable access to essential and important medical services.
  • Do you provide a toll-free Member Services number for the retail and mail-order programs?
    Yes. Five Points provides a single, toll-free telephone number that members can call for both medical and pharmacy benefit questions. In addition, each mail-order vendor provides a toll-free customer service line for members to check the status of their orders, request prescription refills or speak with a pharmacist about their medications.
  • Does your program offer prospective, concurrent, or retrospective drug utilization review?
    Yes.
  • How can I tell if my Pharmacy Plan meets Creditable Coverage requirements?
    The Centers for Medicare and Medicaid Services (CMS) provide general information to employers about Medicare Part D Creditable Coverage requirements and model disclosure notices. See CMS information on creditable coverage >
  • Does a group or a subscriber within a group have to take prescription drug coverage?
    We offer multiple plan design options for our customers encompassing a variety of plan provisions. As a result, group contracts vary by customer. However, a plan administrator may opt to offer several different plans to provide choices for their members. If more than one option is available, members can select a benefits plan that includes or excludes prescription coverage. Once a member selects a plan, coverage is provided as a package.
  • How many retail networks do you offer nationally?
    We offer a single national pharmacy network that provides members with access to over 67,000 pharmacies located in 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. The network includes 82% of the independent and chain pharmacies on our secure member site or by calling Member Services at the toll-free phone number on your Member ID card.
  • How do members obtain covered prescription drugs via mail order?
    Plan members receive an enrollment kit that includes the order forms and envelopes they need to request covered prescription drugs via mail-order delivery (where mail-order is available). To order a drug, the member completes an enrollment form and submits the profile information (with the first order only) and the original prescription(s) in the pre-addressed envelope. The member must include a check for the appropriate copayment(s) or provide a credit card number. If a member needs a mail-order brochure and order form to submit for an initial supply of medication, they should call the toll-free Member Services number on their Member ID card. After the initial form has been submitted, members can either call in refills using a toll-free phone number or mail a refill request. Members can also order refills via the Internet by accessing their mail-order provider's website directly. Members who have CVS Caremark Mail Service Pharmacy as their mail-order pharmacy can order refills or check the status of their order online. Members can link to CVS Caremark Mail Service Pharmacy by logging on to Five Point's self-service secure member website. Members can also request refills by calling CVS Caremark Mail Service Pharmacy directly. Generally, orders will be delivered, postage paid, by U.S. mail or another carrier within 14 days if they are "clean" and do not require intervention.
  • Do you use a preferred drug list (also called a formulary) and are members limited to using these preferred drugs?
    Optum Rx uses a preferred drug list of effective and affordable drugs approved by the U.S. Food and Drug Administration. In selecting drugs for this list, Optum Rx focuses first on quality before considering cost. Many drugs on the preferred drug list are subject to rebate arrangements between Optum Rx and the manufacturer of those drugs. Formulary requirements vary depending on the prescription drug plan design. Prescription drug benefit plans with an open formulary cover all drugs, except contractually excluded drugs, with some plans requiring different copayments for generic, brand-name formulary and brand-name nonformulary drugs. Open formularies are available with Optum Rx PPO-based and indemnity pharmacy plans and HMO pharmacy plans, where filed and approved. In certain HMO service areas, plans are available with a closed formulary. Closed formulary plans do not cover a group of products listed in the Optum Rx Formulary Guide as Formulary Exclusions. A physician may request coverage for a drug on the Formulary Exclusions List by providing the Pharmacy Management Precertification Unit with clinical documentation supporting the drug's medical necessity. Contractually excluded drugs are not covered under closed formulary plans as well. To learn about Pharmacy Management's guidelines for determining health care coverage for selected outpatient prescription drugs on the Formulary Exclusions List or those drugs requiring precertification or step-therapy, see our Pharmacy Clinical Policy Bulletins.
  • When can I apply for a health plan?
    In general, you can only change or apply for health care coverage during the yearly open enrollment period (OEP).
  • How much is it going to cost me for a specific service or procedure?
    You can sign in to My Health Toolkit on the website. Under the Resource tab, there's a link to Find Care. Select Procedure Costs.
  • How do I find information on how Five Points paid my claim?
    You can call us at 915-803-4198.
  • Do I have benefits for telemedicine? If yes, what are the benefits and how does this process work?
    More info.
  • How do I request a review of a processed claim?
    Review and appeal information is on your EOB. You can access your EOBs through my Health Toolkit. You can also review claims and check claims through the portal. If you have more than one claim and need help understanding all the information, this is a good place to review all your claims at once.
  • What are our operating hours?
    Monday to Friday, 7AM to 5PM
  • How do I find doctors covered by my insurance?
    You can do this in a number of ways. You ca sign in to My Health Toolkit on the website. Under the Resources tab, there is a link for Find Care. There is a Find Care icon in the bottom right corner. In the members section of the website you can choose Find a Doctor online provider directories.
  • What do I need to consider when choosing a health plan?
    Health insurance works by helping you pay for medical care and services, so you don't have to pay all your health care costs on your own. The best health plan for you is one that meets your health care needs, budget, and expectations. But it can be tough to know what to look for - and what to avoid. Before you decide on a plan, you'll need to think about: Your health and how often you need care How much coverage you need How much money you're willing to spend How different health plans work What each plan offers beyond the basics Understanding your total health care costs is key to getting the most out of your plan and avoiding potentially expensive surprises.
  • What are my deductible and out-of-pocket amounts?
    When you log in to My Health Toolkit online or through the mobile app.
  • How do I obtain an ID Card or additional ID Cards?
    Review your member ID card information carefully and call us at 915-803-4198 or email us at alejandra@fivepointsmecplan.com if you have questions regarding your member ID card.
  • Can I upgrade my plan at any time?
    Absolutely! There is no wait time to upgrade your health plan. You can call us at 915.803.4198 or email us at alejandra@fivepointsmecplan.com, and we will be more than happy to assist you.
  • How do I add or remove dependents on my policy?
    More info.
  • What are the benefits for specific service or treatment?
    You can look up details about your coverage in My Health Toolkit.
  • Do you offer dental and vision?
    Coming Soon
  • How do you enroll?
    Please contact our office at 915.803.4198 and one of our agents will assist you with enrollment
  • What benefits do you receive?
    Coming soon
  • What is your "Provider Network"?
    First Health Network PPO with over 1 million providers nationwide
  • Who can become a Five Points Health Benefit member?
    Coming Soon
  • We can't switch until the end of our plan year, right?
    Coming Soon
  • Do all of my employees need to be in one of the listed states?
    Employees can be located anywhere in the U.S., there are no state restrictions on using your Five Points Health Benefit plan.
  • How many employees do you need to be a "company"?
    Two is the minimum to be a "company"
  • How can I check if my doctor is in-network?
    Use Five Points' First Health Provider Search tool to search our network of partners including a variety of modern and accessible providers who are available for almost everything.
  • How does Five Points save me money?
    Five Points negotiates pricing with providers according to objective, industry-accepted metrics. By reducing provider markups, premiums become more manageable. Five Points also provides level-funded plans, which allow you to receive a credit or refund if you do not spend what was budgeted in your premiums. Small businesses can deduct the cost of employee premiums from their federal tax filings. Depending on your situation, additional tax credits may be available.
  • What are the types of Individual and Family plans Five Points Benefit Plans offers?
    Coming Soon
  • What does Silver, Gold, and Platinum on the Individual and Family plans mean?
    Individual and Family plans are organized into 3 coverage levels and getting to know them will help you understand what you are responsible for paying and which plan will best fit your health care needs. It is important to understand that the metal tiers reflect a difference in cost. You receive our high quality Five Points service in all of our plans.
  • Can I purchase individual and family health plans at a lower cost?
    Healthcare costs can be overwhelming for many individuals and families. The Affordable Care Act (ACA) makes it easier for individuals to compare a variety of health insurance plans and select the one that best suits their needs and budget. The ACA also provides financial assistance (sometimes referred to as subsidies) to qualified individuals based on income. You can also compare plans, calculate your rate, and apply for health plans. Learn about Individual & Family health plan affordability by contacting us at 915-803-4198 or by email at alejandra@fivepointsmecplan.com to learn more.
  • When can I enroll?
    Open enrollment is 365 days a year.
  • Do you have to be a college student?
    No, you may be a student first grade and up.
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