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Medicare Advantage Out-of-Network Coverage Rules

HMO Plans:

  • You must get all of your health care from doctors in our network. 
  • With limited exceptions, while you are a member of our plan, you must use network providers to get medical care and services.
  • The only exceptions are emergencies, urgently needed care when the network is not available (generally when you are out of the service area), out-of-area dialysis services and case services in which Senior Blue HMP authorizes use of out-of-network providers (your provider must obtain authorization from us). 

 

PPO Plans: 

  • As a member of our plan, you can choose to receive care from out-of-network providers.
  • Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. 
  • If you use and out-of-network provider, your share of the costs for covered services may be higher. 
  • If you are using an out-of-network provider for emergency care, urgent care, or out-of-area dialysis, you may not have to pay a higher cost-share amount.

 

POS Plans:

  • While you are a member of our plan, you must use network providers to receive medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally when you are out of the service area), out-of-area dialysis services and cases in which Senior Blue HMO authorizes use of out-of-network providers (your provider must obtain authorization from us)
  • In addition, Point-of-Service (POS) members have the option to get select medical care and services from an out-of-network provider at an additional cost. (Certain benefits covered up to $1,500 per year). 
  • Emergency care, urgently needed care, and out-of-area dialysis do not count towards the benefit maximum. 

 

Prescription Drug: 

  • You generally must use a network pharmacy to fill your prescription. 
  • We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. 
  • Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. The circumstances when we would cover prescriptions filled at an out-of-network pharmacy include: 
    • There are not network pharmacies within a reasonable driving distance that provides 24-hour service
    • If you are trying to fill a prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy
  • Always check with member services to see if there is a network pharmacy nearby for you.

 

If you move out of the area that BlueShield of Northeastern New York services, you must notify the plan so that you can disenroll and find a new plan in your new area. If you permanently live out of the service area for longer than 6 months, you are no longer eligible to be enrolled in our plan. 

 

For more information about out-of-network and cost-sharing, refer to the Summary of Benefits or the Evidence of Coverage.

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