PCP - HMO plans require the use of a PCP. All medical care must be directed through your PCP. Family or general practitioners, internists, or pediatricians can be selected as a PCP. You and your dependents may each choose a different PCP from a listing provided by the HMO. You are allowed to change PCPs during the year. If you fail to select a PCP, you will either have coverage for emergencies only, or the HMO will assign a PCP for you. When selecting a PCP, it is your responsibility to make sure the PCP is accepting new patients.

Please note: If your PCP or Specialist withdraws from your medical plan, you are required to choose another network physician. You may not change plans at this time.

Specialty Care - If you need ongoing care from a specialist and the medical plan requires referrals, the plan must have a procedure in place to allow a standing referral to that specialist. These treatment plans must be approved by your PCP and HMO and may be limited to a specific number of visits or period of time.

In the event specialty care you need cannot be provided by a network provider, you may obtain services through a non-network provider. To receive network benefits, the referral must be authorized in advance by your HMO to the non-network provider.

Pre-Authorization - Pre-authorization must be obtained by your PCP.

Care Received Outside the Service Area - Contact your PCP or HMO for the proper procedure in obtaining care. If this procedure is not followed, charges will not be covered except for emergency care.

Urgent Care - Contact your PCP or HMO for the proper procedure in obtaining care. If this procedure is not followed, charges will not be covered.

Emergency Care - Emergency care is any emergency medical condition leading a prudent layperson to seek immediate medical attention. You must notify your HMO or PCP within 24 - 48 hours after seeking care.

Examples of medical emergencies include, but are not limited to:

• conditions placing a person’s health in significant jeopardy;
• serious impairment to a bodily function;
• serious dysfunction of any bodily organ or part;
• inadequately controlled pain; or situations when the health of a pregnant woman or her unborn child are threatened.

Continuation of Care - State law provides that contracts between the medical plans and their providers include provisions for continuation of care for a period of up to ninety days. If a provider terminates or is terminated from the network where the continuation of care is medically necessary (i.e. disability, pregnancy, or lifethreatening illness) you may be authorized by your medical plan to continue seeing the terminated provider. You will be responsible for applicable network copayment amounts. Contact your medical plan for authorization.

Claims for Non-Network Providers - Contact the appropriate plan to find out:

1. How, when and where to obtain claim forms, if required, and
2. The requirements for providing notice of claim and proof of loss. If it was not reasonably possible for you to give notice within the specified time, claims shall not be invalidated or reduced

Out-of-Pocket Maximums - Network out-of-pocket maximums are limited to no more than 50% of the cost of providing a single service. Copayments are also limited to no more than 20% of the cost of providing basic healthcare services for the total benefit period. In addition, copayments may not exceed 200% of the total annual premium.

Important - Participating providers may change during the year. You should contact the medical plan to verify provider information and to obtain provider directories (see Plan Addresses and Phone Numbers).