HMO Guide

A Simple Guide to Using Your HMO Benefits

This page summarizes some of the most frequent questions members ask about Using Your HMO Benefits.  PacFed is dedicated to providing you with quality health care and service.  The more you understand how your Health Plan coverage works, the better your ability to use the services available. The Member Assistance Department is available to provide you with assistance when you need it. For more information or answers to other questions regarding coverage, please contact the Member Assistance Department at PacFed Benefit Administrators (PacFed).

  1. What is a Primary Care Physician?
  2. How do we choose the right Primary Care Physician?
  3. How do I use my medical identification card?
  4. What if I need to see a specialist?
  5. Can I change my Primary Care Physician?
  6. What is an emergency?
  7. What if my doctor's office is closed and I need medical care?
  8. What if I need to see a doctor while away from home?
  9. Will I receive any medical bills?
  10. Where and how often can I get my prescription filled?

1. What is a Primary Care Physician?

The foundation for Health Maintenance Organizations (HMO) is your relationship with your Primary Care Physician. A Primary Care Physician is usually a general practitioner or family practice physician who manages all your health care or medical needs, which includes your basic care, preventive services, referrals to specialist and hospitalization arrangements.

Always contact your Primary Care Physician first for any health care needs. Your Primary Care Physician or associate is available 24 hours a day.

2. How do we choose the right Primary Care Physician?

Use the Provider Directory to select a physician nearest to your home or work. Your medical records will be maintained at your selected Primary Care Physician.

3. How do I use my medical identification card?

You will each receive a medical identification card with you and your eligible dependents selected Primary Care Physician's name, address, phone number and your personal identification number. Carry your card at all times and have it available when you call or visit your doctor.

4. What if I need to see a specialist?

Your Primary Care Physician, in consultation with his colleagues, will determine the proper treatment and refer you to a specialist when needed.

Ask your Primary Care Physician how long the referral authorization takes. If you feel the referral process is taking too long, call the PacFed Member Assistance Department for assistance.

Remember: All medical care must be coordinated by your Primary Care Physician, or the cost of the service may not be covered.

5. Can I change my Primary Care Physician?

Yes. You may change Primary Care Physicians once a month. You will need to complete a transfer request form. These may be obtained at your assigned medical provider's office or by contacting the PacFed Member Assistance Department.

Transfer forms must be received in the PacFed office by the 15th of the month to be effective the 1st of the following month.

Example : If your completed form is received on June 10th, the change will be processed so you can see the new doctor July 1st. If your completed form is received on June 19th, the change will be processed so you can see the new doctor beginning August 1st.

6. What is an emergency?

An emergency is defined as an illness or injury that threatens a person's life.

7. What if my doctor's office is closed and I need medical care?

For non-life threatening conditions you should call the 800 number on the back of your medical identification card for instructions. If your condition is life threatening or may cause permanent damage to your health or limb, call 911. Once your condition is stable you or a family member should call the 800 number on the back of your identification card to report your medical emergency. The Plan must be notified within 48 hours.

8. What if I need to see a doctor while away from home?

Your Medical Plan will cover urgent care or medical emergencies when you are out of the service area. Your co-payment will be slightly higher for urgent care and medical emergencies.

9. Will I receive any medical bills?

It is possible you may receive a bill in error. If you ever receive a bill for charges other than applicable co-payments, do not pay it. Forward the bill to the PacFed Member Assistance Department:

PacFed Benefit Administrators, Inc.
1000 North Central Avenue, suite 400
Glendale, CA 91202
(818) 243-0222
(800) 753-0222
Fax: (818) 549-0610

10. Where and how often can I get my prescription filled?

Most prescriptions can be filled at well known chain drug stores. However, some pharmacies are located in the same buildings as your Primary Care Physician or next door. To be sure, ask the office manager of your Primary Care Physician. Long term medications can be purchased by mail. Call the Health Plan Member for a mail order form.

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