With Excellus BlueCross BlueShield, your employees will have access to more top-quality doctors, hospitals, and pharmacies, locally and nationwide.
SimplyBlue Plus plans have network providers. These are the doctors and other healthcare professionals, medical groups, hospitals and other healthcare facilities that have an agreement with us to accept payment and any plan cost-sharing as payment in full. We have arranged with these providers to deliver covered services to members in our plan.
With a PPO, members don’t need to select a Primary Care Physician, and referrals are not needed. Members have access to both In- and Out-of-Network providers. However, their out-of-pocket costs may be higher when they use an Out-of-Network provider, except in emergencies or urgently needed care. Members do not need a referral or prior authorization (prior approval) when they get care from Out-of-Network providers; however, before getting services from Out-of-Network providers, members may want to confirm with us that the services they are getting are covered and are medically necessary.
We provide reimbursement for all covered benefits regardless of whether they are received In-Network, as long as they are medically necessary. However, members' out-of-pocket costs may be higher when they use an Out-of-Network provider, except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis.
A network pharmacy is a pharmacy that has contracted to participate in our network to provide covered prescription drugs. Our pharmacy network includes retail, mail order, long-term care, home infusion and Indian/Tribal/Urban pharmacies. The same quantity limitations apply to both mail order and retail pharmacies. To obtain a list of network pharmacies, to find out if a pharmacy is in our network, or to get order forms and information about filling prescriptions by mail, call our Pharmacy Help Desk toll-free at 1-800-499-2838, (TTY/TDD 1-800-421-1220).
Generally, members must use network pharmacies to get prescription drugs covered, except under non-routine circumstances, and quantity limitations and restrictions may apply.
We have network pharmacies outside of our service area where members can get their prescriptions filled. Generally, we cover drugs filled at an out-of-network pharmacy only when a member is not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- If the prescriptions are related to care for a medical emergency or urgently needed care.
- If a member is unable to get a covered prescription drug in a timely manner within our service area because
there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
- If a member is trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail
or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
In these situations, please check first with our Customer Service Department to see if there is a network pharmacy nearby.