As background:
Plans through us are a fully ACA compliant major medical health insurance plan. It is a self-funded health plan, meaning the employer is technically the insurer – they are the ones paying your fees, our fees, and funding all claims (payments for health services both inside and outside your four walls).
Understanding the typical plan design:
At a high level, plans can typically be broken down into three tiers:
Tier 1 is DPCs like you, Preferred Providers, and many prescriptions. All this care is $0 to members
Tier 2 is In-Network care or Coordinated Care. To see which Network(s) apply to a member’s plan, see their member ID card
Tier 3 is Out of Network care. This care may still be covered, but will have the highest out of pocket costs for members
Care Coordinators are the member’s first point of contact for finding preferred providers, coordinating referrals and appointments, monitoring claims and precertification requests and more
Pharmacy Benefits are managed through a traditional PBM. However, depending on the member’s need, a Care Coordinator may have an alternative source for brand name or specialty drugs that may be fully covered.