Point of Service Plans (POS)

Choose Your Provider — In or Out of Network

Choose In-network providers
One of the best ways for members to control costs and get the most from their POS plan is to choose an in-network Primary Care Physician (PCP) to coordinate care. PCPs treat you for a wide variety of conditions, provide important preventive care checkups and tests, and make referrals to participating specialists and facilities. POS plan also offer an option to remove the referral requirement thus allowing members to see specialist without obtaining a referral (Open-Access).

Choose out-of-network providers
Members have the choice to see any doctor; however, when they receive care from a doctor or facility that is not in the network, out-of-pocket costs will be higher. Members using out-of-network services must pay the entire cost of any care until they meet an annual deductible. Once the deductible is met, coverage begins and members pay a percentage of the cost (coinsurance) of subsequent care.

Here is a summary of benefits and how a POS works for In-network care:

Routine Medical Care (such as physical exams, mild fever and pains, chronic pain and, headaches, colds and flu):

  • The Primary Care Physician (PCP) will provide medical advice and/or service for a predefined office visit co-payment.


Specialty Care (such as orthopedic or heart disease)

  • The PCP will make an initial assessment, and refer the member to a participating specialist if needed.
  • In an Open-Access POS the member will seek care from a Specialist without the requirement of a referral from a PCP.
  • All services are subject to a predefined office visit co-payment.


Retail Prescription Drugs

  • Members fill their prescriptions at a participating pharmacy for a predefined co-payment.
  • Members fill their maintenance prescriptions at a participating pharmacy and/or a mail order program for a predefined office visit co-payment.


Hospital Care (such as inpatient care and surgery, or outpatient surgery):

  • For non-emergency care, the PCP and or Specialist will coordinate all hospital care.
  • Services are either covered at 100% or subject to a predefined co-payment.


Emergency Care (such as poisoning, chest pains, broken bones, uncontrolled bleeding, loss of consciousness or sudden paralysis):

  • The employee should go to the nearest emergency facility or call 911, and then call the PCP as soon as reasonably possible, so that he or she can coordinate all follow-up care.

Cost Sharing Option (often may refer to services such as inpatient care, outpatient surgery and procedures, radiology and laboratory services):

  • Under this cost-sensitive option, select services are frequently subject to a deductible and coinsurance rather than provided at 100% subject to a co-payment.

Here is how a POS works for out-of-network care. All services are subject to a deductible and co-insurance as well as usual and customary rates (UCR).e.

 

We offer POS plans with the following carriers: