Care from Specialists
When your PCP thinks that you need specialized treatment, he/she will give you a referral (approval in advance) to see a plan
specialist or certain other providers. A specialist is a doctor who provides health care services for a specific disease or part
of the body. Specialists include but are not limited to such doctors as:
- oncologists (who care for patients with cancer);
- cardiologists (who care for patients with heart conditions); and
- orthopedists (who care for patients with certain bone, joint, or muscle conditions).
For some types of referrals, your PCP may need to get approval in advance from our Plan (this is called getting “prior authorization”).
It is very important to get a referral (approval in advance) from your PCP before you see a plan specialist or certain other
providers (there are a few exceptions, including routine women’s health care that we explain later in this section). If you do
not have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.
If the specialist wants you to come back for more care, check first to be sure that the referral (approval in advance) you got
from your PCP for the first visit covers more visits to the specialist.
If there are specific specialists you want to use, find out whether your PCP sends patients to these specialists. Each plan PCP
has certain plan specialists they use for referrals. This means that the PCP you select may determine the specialists you may
see. You may generally change your PCP at any time if you want to see a Plan specialist that your current PCP does not refer
to. If there are specific hospitals you want to use, you must first find out whether your PCP uses these hospitals.