Out-of-Network Coverage

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. Here are three exceptions:

 

The Point of Service (POS) option lets you use doctors and hospitals outside the plan provider network. You may receive all plan covered services from non-network providers, but you will have to pay a higher cost sharing that the one you pay when using in network providers. Please note that the POS benefit covers the United States and its territories. Providers rendering services under this option must be state-licensed or state certified.

This is not the same benefit as visiting out of network doctors and/or hospitals during an emergency or an urgent care. Or, if you need medical care that Medicare requires our plan to cover and we do not have providers available in our network to provide the service, you can get this care from an out-of-network provider. You will need to obtain authorization from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. The plan covers dialysis services for ESRD enrollees who traveled outside the plans service area and are not able to access contracted ESRD providers. Please refer to Chapter 4 for more information about your POS cost sharing, cap on the dollar amount and prior authorization requirements.

 

For detailed information refer to your plan’s Evidence of Coverage or contact Member’s Services