FAQs
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RX Information |
Benefit Information |
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 a 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 a 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 First Health?
Cox HealthPlans is pleased to announce their new partnership with First Health Network to provide Preferred Provider Organization (PPO) network services outside of Cox HealthPlans' own network area effective January 1, 2010. When seeking care outside the Cox HealthPlans service area, PPO members can lower their out-of-pocket expenses by taking advantage of this "wrap network"!
First Health is one of the leading PPO networks in the United States. Today, their network consists of over 490,000 providers, hospitals, and other health care providers in urban, suburban and rural areas throughout the United States including the District of Columbia.
Members are not required to use the First Health 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.
Although a facility (hospital, clinic, etc.) is a contracted provider with First Health Network, this does not ensure that physicians or ancillary providers such as pathologists, anesthesiologists, and radiologists at this facility are contracted with First Health. Services and items requiring pre-authorization, including Inpatient, Outpatient, and Emergency Services, will be the covered person's responsibility to report to Cox HealthPlans. For questions concerning the procedures that require pre-authorization, contact Member Services at (417)269-2900 or (800)205-7665.
How do I contact First Health?
- Visit the First Health online provider directory called "Locate a Provider" at www.firsthealth.com
- Call First Health at (800) 226-5116 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.
If you have any questions or concerns, or need additional assistance, please contact the Member Service Department:
Phone 417.269.2900 or 800.205.7665 Fax 417.269.2949 E-mail members@coxhealthplans.com
Mailing Address
Cox HealthPlans
PO Box 5750
Springfield, MO 65801-5750
Or visit us at
Cox HealthPlans
Kelly Plaza
3200 S. National, Building B
Springfield, MO 65807