Page 68 - EPO_Member_Kit

Basic HTML Version

T H E F A C T S A B O U T Y O U R P L A N – E P O
What Does EPO Stand For:
EPO stands for Exclusive Provider Organization. You
receive care from Alliance-affiliated doctors within our
provider network.
As an EPO enrollee:
• You do not need to select a personal care
physician (PCP).
• You do need to receive all
preventive care
from
in-plan providers. If you choose to receive any
preventive services from an out-of-plan provider,
these services will not be covered and you will be
responsible for payment.
• You also need to receive all specialty care from
in-plan providers. You do not have out-of-plan
coverage.
• Whether your medical visit is for preventive or
specialty care, you will be responsible for your
cost-sharing amounts like your copay.
• Out-of-plan specialty services will only be covered
if the services are not available in your doctor’s
network and are approved by the plan’s Medical
Director.
As an Alliance enrollee, the three main types of costs
you are responsible for are coinsurance, copays and
deductibles.
Coinsurance
is the percentage of charges that you are
responsible for paying when you receive covered
services. For example, if your Group Health Insurance
Policy states that Alliance will pay 80 percent of
allowable charges for covered services (after your
deductible and/or copays have been met) then the
remaining 20 percent is your coinsurance.
A
copay
is the amount you pay at the time of service.
Typically copays are for doctor office visits and
prescription medications.
Your
deductible
is the fixed amount that you must pay
before your health benefits begin to cover medical
services. After the deductible is met, covered services
are payable at the allowable charge, based on the
specific provisions of your Group Health Insurance
Policy. Services must be a “covered” benefit to be
applied towards the deductible.