Medical Coverage
Your Medical Plan Options The medical options available are provided by Anthem Blue Cross. To help guide your plan selection, the following pages include details concerning how the plans will operate, as well as plan highlights and features. The rates for any coverage will be found in the online enrollment system and at the end of the guide. Using an HMO Plan A Health Maintenance Organization (HMO) plan requires you to see physicians that are only in network, and you will need to identify a primary care physician (PCP) to direct your use of the network and provide referrals to specialists and other in network services. • With the exception of an OB/GYN specialist who is affiliated with your selected medical group, you must receive a referral from your PCP before receiving services from a specialist • You and your enrolled dependent(s) are not required to see the same PCP, and you may change your PCP monthly, with the new PCP becoming effective on the first of the month following the change • Services may require a co-pay up front • You do not have to submit claim forms • Any services rendered out-of-network without the proper referral from your PCP will not be covered • Preventative is covered 100% Using an EPO Plan An Exclusive Provider Organization (EPO) is a health insurance plan that only allows you to get health care services from doctors, hospitals, and other care providers who are within a certain network. Your insurance will not cover any costs you get from going to someone outside of that network. The only exception is that emergency care is usually covered. Generally, an EPO operates as follows: • EPO plans only cover the cost at doctors or health providers that are within your network • Emergency care is covered, even if it’s out of your network • You do not need a referral if you want to see a specialist with EPO insurance • An EPO is a hybrid between an HMO and PPO plan
Using a PPO Plan A Preferred Provider Organization (PPO) medical plan allows you to see physicians both in network and out of network. You will pay a different fee to see doctors and/or hospitals outside of the network. Generally, a PPO operates as follows: • You may see an in-network doctor or you may go outside of the network for a higher copay. • Some services may still require authorization from a specific doctor or specialist before they may be covered. • Be sure to ask your physician/hospital if they are “in- network” to take advantage of the lower coinsurance. • Services may require a copay up front. • If your physician does not bill the carrier directly, you may submit claim forms for reimbursement if services are medically necessary. Calendar Year Deductibles and Out-of-pocket Maximums The calendar year deductible as well as each plans Out-of- Pocket maximum, aligns with the Calendar Year (January 1st - December 31st); they do not reset on the Benefit Plan Year (November 1st - October 31st). Selecting a Plan that is Right for You As you evaluate your health plan options and insurance needs, consider the following factors: • CHOICE: If you prefer to obtain services from specific physicians, specialists or facilities, check to see if the medical plan option will cover services from those providers. While some health plans restrict your provider selection, others provide greater flexibility and choice • CO VERAG E: Whether routine, surgical, prescription or another type of coverage, determine if the plan covers the services and medical treatments you value most. Plan exclusions, restrictions and limitations may also influence your selection • COST: Cost may be a large determining factor in your selection and each plan may contain a variety of cost components. Consider the amount of your payroll deduc- tion, as well as other plan expenses such as deductibles, copayments or coinsurance You are encouraged to review the complete Summary Plan Descriptions (SPD) of each plan. Do you have questions regarding a plan? To correspond with a plan representative, refer to the Directory & Resources section for important contact information.
Benefits Guide 2025-26 5
Made with FlippingBook - Online magazine maker