Frequently Asked Questions
Plan Information
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Provider Information
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RX Information
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Benefit Information
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What is an HMO?
A Health Maintenance Organization (HMO) is a type of health plan that provides health care in return for set monthly payments. Most HMOs provide care through a network of doctors, hospitals, and other medical professionals that members must use in order to be covered for care. For the member, it means reduced out-of-pocket costs (i.e., no deductible), no paperwork (i.e., insurance forms),and only a small copayment for each office visit or prescription.
What is an PPO?
A Preferred Provider Organization (PPO) is a network of heath care providers who contractually agree to provide quality health care under strict utilization requirements at appropriate costs. Payers agree to encourage their subscribers or employees to use providers who have agreed to supply services at a specified cost. The agreement is designed to reduce costs for payers and, in return, supply additional patients to providers. It can be sold through an underwritten or self-funded arrangement.
What is an POS?
A Point of Service (POS) is a type of health care plan that allows members to choose to receive services either from participating HMO providers, or from providers outside the HMO's network.
What is HIPAA?
A U.S. regulation that gives patients greater access to their own medical records and more control over how their personally identifiable health information is used. The regulation also addresses the obligations of healthcare providers and health plans to protect health information.
What is a Non-Participating Provider?
A provider who has not signed an agreement with the Plan to provide services to members.
What is PHCS?
PPO members:
Members who reside outside of Cox HealthPlans' southwest Missouri network area, the PHCS "PPO Network" will serve as the primary PPO network to access in-network benefits where the member lives; the PHCS logo will be located on the front of the ID cards for these members.
Members who reside within Cox HealthPlans' network area but are seeking care outside of southwest Missouri, providers can be accessed via PHCS for in-network benefits (these members must use the PHCS "Healthy Directions" Network).
Dependent children who are attending college outside of Cox HealthPlans' network area may also access providers in the PHCS Network for in-network benefits (these dependent children must use the PHCS "Healthy Directions" Network if the EMPLOYEE resides within the Cox service area; otherwise they must use the PHCS "PPO Network").
HMO members are served by the PHCS Network in the following manner:
For HMO members covered by a Point-of-Service rider, members can access discounted care outside of southwest Missouri utilizing the PHCS "Healthy Directions" Network. (Please note that claims will be administered as POS (non-network) benefits, but the member may realize savings by utilizing a contracted provider).
For HMO members not covered by a Point-of-Service rider, any care outside of the Cox HealthPlans network will still require prior authorization by Cox HealthPlans in order for the member to receive in-network benefits.
Members are not required to use the PHCS Network for unplanned or emergency treatment while outside the service area, but doing so will help to limit the out-of-pocket expenses and maximize their benefit level.
Please note that Cox HealthPlans will only utilize PHCS outside of Cox HealthPlans' service area. Providers in the PHCS Network who are within the Cox HealthPlans service area will not be recognized as in-network providers.
How do I contact PHCS?
- Visit the PHCS online provider directory called "Find a Provider" at www.phcs.com
- Call PHCS at (888)978-7427 Monday through Friday 7a.m. to 7p.m. (CST)
- Call Cox HealthPlans Member Services Toll Free at (800)205-7665
What is a participating pharmacy?
A pharmacy which agrees to provide service under the terms set forth by the Plan's Pharmacy Benefit Management company.
What is a single source medication?
A single source medication or drug is one that is currently manufactured by only one company and is still under patent with no generic drugs available.
What is generic medication?
A generic medication is one that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name.
What is a formulary?
A formulary is a list of drug products, approved by the Plan's Pharmacy and Therapeutic Committee that are available for use by Members.
What is a brand name medication?
A brand name medication is one that is manufactured and distributed under a product name and may have generic medication versions available.
What is an EOC/Benefit Booklet?
An Evidence of Coverage (EOC)/Benefit Booklet is a detailed description of the provisions and limitations of the plan.
What is an out-of-pocket maximum and what does it include?
An out-of-pocket maximum is the total amount of copayments and co-insurance a Member is obligated to pay during the calendar year as defined by the Contract. It includes all copayments and co-insurance except for prescription drug copays.
What is considered a calendar year?
A twelve month period beginning January 1 ending December 31.
What is a copay or copayment?
The amount members must pay when they receive covered services that are not fully prepaid.
What is co-insurance?
The percentage payable by the covered person for covered expenses.
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