Most Americans who have health insurance through their employer, self-insured or Medicare are enrolled in some type of a managed care plan. The type of managed care plan you have may determine how you access and receive health care for you and your family, and what you will have to pay out of pocket each time you receive care.
If you are enrolled in a HMO you will need to receive most or all of your health care from a network provider. HMOs require that you choose a primary care physician (most often an internist, family doctor, or pediatrician for your children) who is responsible for managing and coordinating all of your health care. If you need care from a physician specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with an order or a referral. If you do not have a referral or you choose to go to a doctor outside of your health plan’s network, you will most likely have to pay all or most of the cost for that care.
Managed care plans typically cover a wide range of health services such as preventative care and immunizations for adults and children, general checkups, diagnosis and treatment of illness (including necessary tests, doctors’ visits, prescription medications, and hospital care and complete prenatal (pregnancy) and newborn care.
Managed care plans save money by providing preventive health care services to help avoid serious health problems. Many common chronic health conditions (such as diabetes, high blood pressure, and high cholesterol) can be prevented from getting worse if diagnosed and treated early. Also, managed health plans save money by contracting with doctors and hospitals in your community to help control the fees they charge. These cost savings may help to somewhat hold down the rising cost of health insurance premiums.
Most managed care plans have a formulary, or list of drugs that they cover. Your health plan may only pay for medications that are on that list. Your copay for a prescription drug will depend on whether you get a generic medication, a brand name medication that is preferred by your health plan, or a brand name medication that is not preferred your health plan. Additionally, your health plan may have lower copayments for prescription medications that you obtain through mail order, rather than through a regular retail pharmacy.
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