Frequently Asked Questions

Common Health Plan Questions

Common Capstone Questions

Common Provider Questions

Common Benefit Questions

Common Pharmacy Questions

Common Health Plan Questions

What makes Capstone the health care plan of choice?
Capstone is the only health plan in Arizona that is exclusive to those with Developmental Disabilities. With a friendly and caring staff to help you, we look forward to your calls.

How do I become a Capstone Member?
Contact your local Department of Economic Security Division of Developmental Disabilities (DES-DDD) or your local Arizona Long Term Care System (ALTCS) office. You must be enrolled with DES-DDD/ALTCS to become a Member of Capstone Health Plan.

How can I change health care plans?
Open enrollment is during during your birthday month. Call Health Care Services at (800) 624-4964 and let them know you choose Capstone Health Plan.

When can I change health care plans?
You can change health care plans during your birthday month.

Common Capstone Questions

How do I get duplicate ID cards?
Just call Capstone Health Plan's Member Services at (800) 336-3874 to request a card.

What do I do when I get medical bills?
Do not pay them. Send them to:
Capstone Health Plan, Member Services

Capstone Health Plan
914 N San Francisco St.
Suite A
Flagstaff, AZ 86001

Common Provider Questions

Can I choose my own Primary Care Provider (PCP)?
Yes, as long as she/he is contracted with Capstone Health Plan.

Can I change my Primary Care Provider?
Yes, call Capstone to do this. You can change up to three (3) times per year.

Can I choose my own specialist?
Yes, as long as the specialist has an AHCCCS provider ID number, and the service has been authorized.

What services have to be authorized first by Capstone?
Visits to your Primary Care Provider (PCP) do not have to be authorized before you go. However, if your PCP wants you to see a specialist, this must be authorized first. Also, medical equipment must be authorized first.

If I have Medicare or other insurance, do I still have to get an authorization from Capstone first?
Yes. Although you may have other insurance, there is usually a co-payment that other insurance will not pay. If you want Capstone to cover the co-payment, those services that require a prior authorization must go through the usual process.

Can a specialist refer me to another specialist?
No, only a Primary Care Provider (PCP) can refer you to a specialist. However, once you have been referred to a specific specialist, that same specialist may request follow-up appointment authorizations through Capstone without getting a new referral from your PCP.

Is a dentist considered a specialist? Does dental care require a prior authorization?
Yes, a dentist is considered a specialist; however, if you are 20 years old or younger, you do not need prior authorization to have routine dental services. If you are 21 years or older, only "emergency" dental services are covered.

Common Benefit Questions

What if Capstone denies a service or medical equipment that my Primary Care Provider (PCP) has requested for me?
You and your PCP will receive a "letter of action" that describes why the service or equipment has been denied. Included in the letter is a description of how you may appeal this decision. You have 60 days from the date of the letter to appeal.

How do I get medical equipment that I need?
Medically necessary equipment needs to be ordered through your Primary Care Provider (PCP). Your PCP will work with you to determine what you need and will forward the request for authorization to Capstone.

What if my therapist thinks I need medical equipment?
Your therapist should write a letter to your Primary Care Provider (PCP) describing what you need and why. If your PCP agrees with this recommendation, then he/she may forward the request for authorization, along with the therapist's letter, to Capstone.

Is there a vision benefit through Capstone?
Yes, routine vision exams and glasses are a covered benefit for Members under the age of 21. Capstone also covers emergency eye care and treatment of medical conditions of the eye for all Members. Routine annual vision exams are also covered for Members of any age who are diagnosed with Diabetes.

What is considered "emergency" dental care?
Emergency dental care for adults 21 years of age or older may include immediate procedures for:

Are diapers a covered service?
Yes, diapers (incontinence briefs) are covered for Members over age 3 and under age 21 and when the primary care doctor submits a prescription and documentation of a disability that causes incontinence of bower and/or bladder. Coverage for diapers is limited to 240 per month, except for special medical reasons, which would require additional information from your doctor.

Can we get pull-ups instead of diapers?
Pull-ups can be approved if documentation is submitted to Capstone that the child is currently involved in a bowel and/or bladder toileting program. Documentation may include information included in an Indvidual Service Plan (ISP) or Individual Education Plan (IEP). If approved, the pull-ups authorization will only be good for one year to transition the child to independent toileting. If the child continues to need incontinency briefs after one year, then the authorization will be changed to diapers.

How do I get a ride?
Contact Capstone 24 hours before you need a ride. Have all of your information available, including the appointment time and provider's address.

How do I get reimbursed for providing my own transportation?
If you drive or someone you know drives you to a Capstone or CRS covered appointment, we can reimburse:

You need prior authorization when:

Common Pharmacy Questions

Where can I get my prescriptions filled?
You may take your prescription to any national chain pharmacies and many smaller, independent pharmacies.

What if my prescription is for a medicine Capstone does not cover?
The prescribing health care provider will have to request a prior authorization.

Does Capstone cover over-the-counter medications?
If you have a written prescription some over-the-counter medications (non- prescription medications) are covered.

How do I get CRS and/or RBHA/NARBHA medications?
Through the CRS or RBHA/NARBHA pharmacy programs. Capstone does not pay for these prescriptions. Do not use your Capstone ID card to get these prescriptions.

How do I get refills?
The label on your prescription tells you how many refills your PCP has ordered. You may only get one refill at a time. If you do not get automatic refills, call the prescribing health care professional at least two days before you run out.

What if I am going on vacation?
Please contact Member Services for assistance.

What if I have other insurance?
We will pay your co-pays for you!

How can I be reimbursed for prescriptions I paid for?
Call Member Services to see how to get your money back. Please do not send requests without a receipt or with receipts that are over 90 days old.

Capstone Health Plan