Answers to commonly asked questions

Below are common questions our members ask. If you don't find the answer to your question, call Member Services.

How do I contact the Mercy Care Member Services department?

Mercy Care and Mercy Care Long Term Care
Monday through Friday 7 a.m. to 6 p.m.
602-263-3000 or 1-800-624-3879
(TTY/TDD) 711

Mercy Care Advantage
8:00 a.m. - 8:00 p.m., 7 days a week
602-586-1730 or 1-877-436-5288
(TTY/TDD) 711

What should I do if I lose my member ID card or don’t get one?
You can call Member Services at one of the numbers above to get a new ID card. TTY users should call 711. 

What is a PCP?
A PCP is a “primary care physician” (doctor) you choose from the Mercy Care network to provide your routine and preventive care.

Can I Choose My Doctors?
Mercy Care has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network, except in an emergency. The health providers in our network can change at any time. You can look for doctors in our network by looking at our current Provider Directory or by using our on-line Provider Directory search tool. You may also contact our Member Services department for assistance in locating a doctor or to change your PCP. 

How will I know the name of my PCP?
Mercy Care will send you a welcome letter when you join. Your welcome letter will have the name and telephone number of your assigned PCP.

Can I change my PCP if I need to?
Yes. Call Member Services.

How can I check the status of my authorization?
Visit the Mercy Care Web Portal or call Member Services to check the status of your authorization. 

How do I know which services are covered and which are not?
Lists of services that are covered and not covered can be found:

Look under the section that applies to you. You may also call Member Services to discuss covered benefits with a Mercy Care representative.

I am a member of Mercy Care or Mercy Care Advantage. What should I do if I get a bill?
If you get a bill, call the health care provider and give them your Mercy Care information. If they continue to bill you, please call Member Services for help. 

I need help getting to my doctor. What can I do?
Check first with neighbors, friends or relatives for a ride. If you are not able to find a ride, please call Member Services for help.

Which hospitals can I use?
Mercy Care has many participating network hospitals. Use our website to find a provider, or check your provider directory. You can get emergency health care services without the approval of your PCP or Mercy Care health plan when you have a medical emergency. You may go to the nearest emergency room or other setting for emergency care. If you have to be hospitalized for any reason, you may go to the hospital your doctor sends you to. 

What is an emergency?
An emergency is a medical condition that could cause serious health problems or even death if not treated immediately. Learn more about when to go to the emergency room and when to see your doctor.

Do I have urgent care if I need it?
Mercy Care has urgent care centers in Maricopa, Pima and Yuma counties. Select Find a Provider, to see our list of urgent care centers.

Which dentist can I see?
You can search for a dentist on our Find A Provider page. 

Visit our Dental page for more dental benefits information for Mercy Care and Mercy Care Advantage members.

How do I see a specialist provider?
Your PCP will make a referral to a specialist provider when necessary.

What if I have an emergency while in another state?
Go to the nearest emergency room and present your Mercy Care or Mercy Care Advantage member ID card. Do not pay for the services. The emergency department should bill your health plan using the information on the back of your ID card. 

What should I do if I’m pregnant?
Tell us about your pregnancy right away so we can enroll you into a maternity care program. Call Member Services at one of the above phone numbers. 

How do I know if my new baby is covered?
Newborns are eligible for Mercy Care health services from their date of birth. However, AHCCCS will need to issue a separate ID number for the baby before receiving services. To have your baby added for coverage, call your AHCCCS caseworker as soon after the birth as possible. Once you receive your newborn's AHCCCS number, you will need to call Member Services to choose a PCP. Your baby will then be issued a Mercy Care member ID card. 

Who do I call if I have a chronic disease or illness?
Mercy Care has programs to help members with a chronic disease or illness. Learn more online or call Member Services. 

Where can I get behavioral health services?
You can get behavioral health services at your local Regional Behavioral Health Authority (RBHA). You do not need a referral from your PCP for behavioral health services.

Your PCP may be able to help you if you have depression, anxiety or attention deficit hyperactivity disorder (ADHD).

Learn more about behavioral health services online or call Member Services. 

If I have a behavioral health emergency, who do I call?
If you think you might hurt yourself or someone else, please call 911. You can also get help by calling your local RBHA crisis line:

  • Maricopa County - Mercy Care RBHA: 1-800-564-5465 
  • Pima County - CPSA: 1-800-771-9889 
  • Cochise/Graham/Greenlee/Gila/La Paz/Pinal/Yuma - Cenpatico: 1-866-495-6738

Who is eligible to join Mercy Care Advantage?
To be eligible for Mercy Care Advantage (HMO SNP), you must receive Medicaid medical assistance from the State of Arizona and have Medicare Parts A and B and reside in the approved service area.

For 2019, our service area is:

  • For AHCCCS Complete Care Enrollees - Gila, Maricopa and Pinal counties
  • For AHCCCS ALTCS Enrollees - Gila, Maricopa, Pima and Pinal counties
  • For Arizona Division of Developmental Disabilities Enrollees - Maricopa, Pima and Santa Cruz counties

What are my protections in this plan?
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a Medicare Advantage plan decides not to continue, the plan must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

What happens if I go to a doctor who’s not in the Mercy Care Advantage network?
If you choose to go to a doctor outside of our network, you must pay for these services yourself, except in limited situations (for example, emergency care). Neither Mercy Care Advantage, nor the Original Medicare Plan will pay for these services.

Does the Mercy Care Advantage Plan cover Medicare Part B and Part D prescription drugs?
Yes, the Mercy Care Advantage plan covers both Medicare Part B and Part D prescription drugs. Please refer to the Evidence of Coverage for more detailed coverage information.

Where can I get my prescriptions filled if I join this plan?
Mercy Care Advantage has a robust network of participating pharmacies available in our plan service area. You must use a network pharmacy to fill your prescriptions. We may not pay for your prescriptions filled at an out-of-network pharmacy, except in limited situations such as an emergency. The pharmacies in our network can change at any time. You can ask for a current Pharmacy Network List or access the Mercy Care Advantage on-line Pharmacy directory. You can also contact Mercy Care Advantage Member Services at 602-586-1730 or 1-877-436-5288, 8:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 711. 

What is a Prescription Drug Formulary?
Mercy Care Advantage uses a formulary and our formulary has been approved by Medicare. A formulary is a list of drugs covered by Mercy Care Advantage to meet patient needs. We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we must notify members in writing before the change is made. We will send a formulary to you and you can review our complete Mercy Care Advantage Comprehensive formulary online.

If you are currently taking a drug that is not on our formulary or subject to additional requirement or limits, you may be able to get a temporary supply of the drug. You or your doctor can contact us to request an exception or switch to an alternative drug listed on our formulary with your doctor’s help. Call us to see if you can get a temporary supply of the drug.  You can read more details about our Mercy Care Advantage Transition of Coverage policy on the Mercy Care Advantage Part D Prescription Drug Benefits page .

What are generic medications?

  • A generic medication has the same active-ingredient formula as the brand-name medication.
  • Generic medications usually cost less than brand-name medications and are approved by the Food and Drug Administration (FDA).
  • On the Mercy Care Advantage Formulary, generic medications are listed in lower case italicized letters (for example: ranitidine), and brand-name medications are listed in all capitalized letters (for example: ZANTAC).

What do I do if I need help paying for prescription drugs?
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to one hundred (100) percent of drug costs, including monthly premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, or to see if you qualify, call: 

  • 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week;
  • The Social Security Administration at 1-800-772-1213, between 7 a.m. and 7 p.m., Monday - Friday. TTY/TDD users should call 1-800-325-0778; or
  • Your state Medicaid office.

If you are eligible for Extra Help, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help please call the numbers above for more information and to find out if you qualify.

What is a Medication Therapy Management (MTM) program?
A Medication Therapy Management (MTM) Program is a free service we may offer. The Medication Therapy Management Program works to identify members at risk for potential drug-related problems and helps these members better understand the drugs they take. Some members have several complex medical conditions or they may need to take many drugs at the same time, or they may have very high drug costs. This program helps members manage their drugs and helps reduce potential problems. The MTM Program can help you and your doctors get the most benefit from your drugs. You may be invited to participate in a program designed for your specific health and pharmacy needs. You can decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. View more MTM Program details on the Mercy Care Advantage Part D Prescription Drug Benefits page or contact Mercy Care Advantage Member Services.

What if I need a drug that is not covered by Mercy Care Advantage?
As a member of Mercy Care Advantage, you have the right to request a coverage determination, which includes the right to request an exception for a drug not covered on our formulary.  

A coverage decision is a decision we make about your benefits and coverage or the amount we will pay for your drugs.

You can ask us for an “exception” to cover a Part D drug that is not on our formulary.

You can ask for an “exception” for us to waive a restriction on a drug on our formulary, such as a limit on the quantity of a drug. 

Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem, with us or one of our network pharmacies, that does not involve coverage for a prescription drug.

Please refer to our Part D Prescription Prescription Drug Benefits page for more information.