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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're
assuring yourself and your family:
- the attention of a personally selected primary care physician
- a high level of coverage at a reasonable rate
- emergency care anywhere at any time
- preventive care to help you stay healthy in the long run
- a wide choice of quality physicians
- freedom from paperwork when you use participating providers
- an easy-to-use health plan with prompt, friendly service, plus,
- the freedom to choose any provider of your choice at the time medical care is needed.
We encourage you to read the information contained in this brochure and ask the questions you need to make an informed decision. We welcome the opportunity to serve you.
The POS Advantage
By closely managing the way health services are delivered, your POS - or Point of Service plan - 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 physicians who are in the POS network
- following nationally recognized clinical standards
- partnering with select providers, and communicating with you, the member.
With the POS plan, you still have the option to receive medical services from any physician or hospital you choose at any time, although you may pay more out-of-pocket.
Partnering with your Primary Care Physician
OSF HealthPlans contracts with many Family Practice, Internal Medicine and Pediatric 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 network, 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. To receive the highest possible benefits, all services covered by the POS plan must be provided, coordinated or arranged by your Primary Cary Physician. You must select a
Primary Care Physician from our network for each family member.
You do not have to contact your Primary Care Physician first for:
- Routine vision exams from a participating POS provider
- Any obstetrical or gynecological care delivered by a participating POS OB/GYN provider.
- Emergency care. OSF HealthPlans must be called within 48 hours after the emergency visit.
- 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 POS plan will cover the costs at the highest benefit level as outlined in your Certificate of Coverage.
No referral is necessary if you elect to use non-participating specialists. You can also see a participating specialist without receiving a referral from your Primary Care Physician. However, in both of these situations you will be required to pay deductibles and coinsurance.
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 vacationing, or if your dependent is enrolled at an accredited college or university outside the POS plan 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.
OSF HealthPlans provides the same coverage for true emergencies and urgent care whether it is received from a participating or non-participating provider.
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.
About Your Pharmacy Benefits
Prescription drug benefits are part of your POS coverage. As an OSF HealthPlans member, you will receive a
Caremark Member Services identification card and a list of participating pharmacies that are closest to your home. You are responsible for a small copayment per 34-day supply prescription.
If you would like additional information on
pharmacies, you may visit the
Caremark HealthSystems web site or call
Caremark at 800-966-5772.
POS Frequently Asked Questions
DEFINITIONS
Primary Care Physicians are Family Practice, Internal Medicine and Pediatric doctors that provide and coordinate all your healthcare needs.
Participating providers are those under contract with OSF HealthPlans to provide services and include not only physicians and hospitals but also pharmacy and other designated individual services providers.
A referral is a method of preauthorization used by your Primary Care Physician.
A plan deductible is the amount you must pay before OSF HealthPlans begins payment for covered services.
Coinsurance is a cost-sharing arrangement in which you pay a percentage of the cost of medical care up to a yearly out-of-pocket limit.
Copayment is a type of cost sharing in which you pay a small dollar amount for a specific healthcare service.
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