Finding a Doctor

In Network v. Out of Network

In Network
Covered services are paid at 80% after the deductible has been met. The insured’s co-insurance amount is 20% of all costs, excluding prescriptions.
Out of Network
Covered services are paid at 60% of Usual and Customary charges. The insured’s portion is 40% plus 100% billed above Usual and Customary charges.

What kind of doctors are primary care physicians?

Usually, they fall into one of the following specialties:

  • Family Practice Doctors or General Practitioners: These doctors are trained to diagnose and treat a variety of health conditions. If you are young and in good health, a general practitioner is your best bet. Many HMO members select the same general practitioner for their entire family.
  • Internists: Specializing in internal medicine, these physicians are trained to treat health conditions like diabetes and cardiovascular disease. If you are managing high blood pressure, heart disease, or diabetes, an internist is a wise choice.
  • Pediatricians: These doctors only treat children, usually under the age of 12.
  • OB/GYN: Some plans allow women of childbearing age to select an OB/GYN as their primary care physician.

Specialist Physicians

If the Primary Care Physician decides that a specialist needs to be consulted, the Primary Care Physician can issue a referral to you.
In order for the insurance company to cover a consultation fee with a specialist, you must have a referral from your Primary Care Physician or the UTSA Student Health Services. Without the referral, coverage for a specialist consultation fee will be denied by the insurance company.

Diagnostic Testing

Diagnostic testing will require approval from your Primary Care Physician. Should your Primary Care Physician refer you to seek an x-ray treatment or laboratory services, the services will be paid at 80% (in-network) after the annual deductible has been met.