All medical treatment must be coordinated by your selected Primary Care Physician (PCP) in order to be covered by the plan. Your PCP will make any referrals to specialists, if needed. However, no referral is required when accessing care from an OB/GYN provider within your Primary Medical Group (PMG) for an annual well women’s exam. Some HMO plans cover chiropractic care and often there is a special procedure for referrals to chiropractors. Be sure to review your plan details carefully.
You may go to a satellite office of your PMG as long as your PCP authorizes your visit to that facility. Always call your PCP prior to receiving treatment from a new health care provider.
If you go to a medical facility other than your selected Primary Medical Group (PMG), to a doctor who is not part of your PMG, to a private doctor, or to a hospital without your PCP’s authorization—you will be responsible for all medical expenses you incur, unless it is an acute, life threatening emergency.
HMO plans typically define an emergency as those services required for the alleviation of severe pain or immediate diagnosis and treatment of an unforeseen medical condition which, if not treated, would jeopardize or impair your health.
In the case of a life threatening emergency, obtain care immediately. After care is obtained, you must contact your PCP within 24 to 48 hours after the onset of the emergency. A family member, co-worker, etc. may make this call on your behalf. In the case of a non-life threatening emergency, regardless of where you are, call your PCP prior to receiving care. If your PCP is not available, there should be another physician on call who can assist you. If you do not consult a physician at your PMG first, you will be responsible for all charges for acute, non-life threatening emergency services.
Brand Name Prescription Drug Benefit
If you choose to receive a brand name drug when a generic equivalent is available, you will often be responsible for the generic drug cost plus the difference in cost between the generic and the brand name negotiated rate. It is wise to read your plan’s prescription drug benefit carefully so that you understand any and all unique provisions.