OSF HEALTHPLANS - A COMMITMENT TO EXCELLENCE

OSF HealthPlans is committed to providing managed care health coverage with a very personal touch.

When you choose OSF HealthPlans for your health insurance, you are assuring yourself and your family:

• the attention of a personally selected primary care physician
• a full range of preventive health services
• specialist and hospital networks
• no pre-existing condition limitations, and
• minimal out-of-pocket expenses.

We encourage you to read the information on this page and ask the questions you need to make an informed decision. We welcome the opportunity to serve you.

How Your HMO Works

By closely managing the way health services are delivered, your HMO - or health maintenance organization - can assure you and other members of high-quality, medically necessary care that is also cost effective. The OSF HealthPlans HealthCare Management Department is responsible for seeing that this value is achieved. It does so by:

• working with the Primary Care Physicians who are in the HMO network
• following nationally recognized clinical standards
• partnering with select providers, and
• communicating with you, the member.

Partnering with your Primary Care Physician

OSF HealthPlans contracts with many Family Practice, Internal Medicine, Pediatric, General Practice and Geriatric physicians. These doctors - also known as Primary Care Physicians - are listed by name and office location in your Provider Directory. As additional providers join the networks, you will receive updates to add to your directory.

The Primary Care Physician you select will serve as your care manager - helping you stay well, treating illnesses or injuries that do occur, and referring you to appropriate specialty care. All services covered by the HMO must be provided, coordinated or arranged by your Primary Care Physician. You must select a Primary Care Physician from our panel for each family member.

You do not have to contact your Primary Care Physician first for:

• Routine vision exams (if provided under the benefits purchased by your employer) from a participating HMO provider.
• Any obstetrical or gynecological care delivered by a participating HMO OB/GYN provider.
• Emergency care. OSF HealthPlans must be called within 48 hours after the emergency visit. However, this does not guarantee coverage for your emergency visit. You must follow the emergency guidelines outlined in your Evidence of Coverage.
• Mental health/chemical dependency services. For mental health and chemical dependency care, members should call United Behavioral Systems directly at 800-420-5729.

Changing your Primary Care Physician

If you wish to choose another Primary Care Physician, you may do so twice during the plan year, as long as 30 days have passed since your last change.

The Referral Process

If your Primary Care Physician finds that you need additional health resources - such as specialty care, home healthcare, medical supplies and equipment or rehabilitative services - he or she may refer you to another provider. Generally, this provider will be part of the OSF HealthPlans network. If necessary, however, your Primary Care Physician can select providers outside the network. In both instances if approved, your HMO plan will cover the costs as outlined in your Certificate of Coverage.

Obtaining Emergency Care

Under your OSF HealthPlans coverage, you and your dependents are assured of emergency and out-of-area urgent care at all times. This includes coverage if you are temporarily out of town on business or vacation, or if your dependent is enrolled at an accredited college or university outside the HMO service area.

Examples of emergencies include, but are not limited to, heart attacks, poisoning, loss of consciousness or respiration, convulsions, broken bones and severe bleeding. If possible, when you have a concern about whether or not you have an emergency situation, contact your Primary Care Physician before seeking care. An urgent care situation is considered to be a sudden onset of a condition that is expected to worsen if not attended to immediately. If you have questions about whether or not you have an urgent medical situation, contact your Primary Care Physician before seeking care, if possible.

If you or a dependent receive emergency or urgent care, please notify the OSF HealthPlans HealthCare Management Department within 48 hours. Representatives there will instruct you on how we will coordinate your care if continued medical attention is needed.

The OSF HealthPlans HealthCare Management Department number is 309-677-8236 or 800-284-CARE, or 800-375-5713 in the Rockford Area.

About Your Pharmacy Benefits

Prescription drug benefits may be part of your HMO coverage. If so, you will receive a Caremark Member Services identification card and a list of participating pharmacies that are closest to your home (if provided under the benefits purchased by your employer). If you would like additional information on pharmacies, you may visit the Caremark HealthSystems web site or call Caremark at 800-966-5772.

OSF HealthPlans will not pay for services when:

• you obtain services from a specialist or purchase medical equipment/supplies without a referral from your Primary Care Physician.
• you obtain services from a provider that exceed those ordered by the referral.
• you obtain services that are not a covered benefit.
• your OSF HealthPlans membership was terminated prior to your obtaining the authorized services.

HMO Frequently Asked Questions