Member Section FAQ's

1. Where can I get a copy of the formulary?

The Evergreen formulary is now available on-line. Please click in the "Member Section" and request your own copy.

2. Why was my ER visit denied?

The ER should be used for the following: (a) Conditions that would place a patient's health in serious jeopardy (b) serious impairment to bodily functions (c) serious dysfunction of any bodily organ or part. If after review your ER visit, it is determined that emergency services did not meet the criteria, the member will be responsible for the charges incurred.

3. What do I do for medical services while I (or my dependants) are out-of-town?

First, always contact your Primary Care Physician. Your PCP may be able to call in a prescription to a local pharmacy for you until you return home.

If the services needed are considered serious or life threatening, go to the nearest emergency room. Evergreen will ensure payment to non-contracted providers for the appropriate out-of-area emergency services. Routine or urgent care will not be covered out-of-town.

4. Why am I getting a bill from the hospital or physician & what should I do when I receive one?

If you receive any bill for services other than routine co-payments, immediately call Evergreen Member Services. Someone will research your statement and let you know if you are responsible for payment. There are certain services provided that are exclusions of the Evergreen plan, and the member could be responsible for those charges.

5. Can a referral b done by a Specialist as well as my PCP?

The PCP is responsible for requesting the referral and referring patients to an in-network specialist. It is the responsibility of the ordering physician to obtain pre-authorization when required for specific procedures and all hospital admissions. The specialist can get a referral to another specialist if needed.

6. If I am sick, what is the criteria for the physician to schedule an appointment for me?

If a patient needs urgent care, an appointment should be scheduled no later than 48 hours. patients should not be sent to the Emergency Department as a convenience.