Medicare Advantage 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.
- If You Select an HMO Plan...
With an HMO, you must select one of our participating providers as your Primary Care Physician. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from Out-of-Network providers neither Medicare nor Excellus BlueCross BlueShield will be responsible for the costs. See your Evidence of Coverage for more information. Generally, with an HMO, you pay copayments, coinsurance and deductibles for most services.
With an HMO Point-of-Service (POS) plan you have the extra flexibility to get some covered services from doctors, hospitals, labs or other health care providers that are not in our provider network without paying the entire cost yourself. An annual dollar limit applies to this benefit. Once your costs go above this limit you’re responsible for 100% of the remaining costs for the out-of-network services.
- If You Select an PPO Plan...
With a PPO, you don’t need to select a Primary Care Physician, and referrals are not needed. You have access to both In- and Out-of-Network providers and you may see any Medicare participating provider. However, your out-of-pocket costs may be higher when you use an Out-of-Network provider, except in emergencies or urgently needed care. You do not need a referral or prior authorization (prior approval) when you get care from Out-of-Network providers; however, before getting services from Out-of-Network providers you may want to confirm with us that the services you are getting are covered and are medically necessary. Your cost sharing responsibility will be greater Out-of-Network when your Out-of-Network coinsurance is based on the Medicare allowed amount and our In-Network provider contract rate for the service is lower than the Medicare allowed amount.
Excellus BlueCross BlueShield provides reimbursement for all covered benefits regardless of whether they are received In-Network, as long as they are medically necessary. However, your out-of-pocket costs may be higher when you use an Out-of-Network provider, except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis.
Generally, you must use network pharmacies to get your 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 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. 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 you are 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 you are 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 Pharmacy Help Desk to see if there is a network pharmacy nearby.
A network pharmacy is a pharmacy that has contracted to participate in our network to provide your 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 your pharmacy is in our network, or to get order forms and information about filling your prescriptions by mail, call our Pharmacy Help Desk toll-free at 1-800-499-2838, (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday, Saturday 9 a.m. - 1 p.m. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m. To contact us by mail: Excellus BlueCross BlueShield, PO Box 546, Buffalo, NY 14201.
For information on network coverage, how to request reimbursement for Out-of-Network claims, Out-of-Network Coverage or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday – Friday, 8 a.m. to 8 p.m.; From October 1 through February 14, 8 a.m. to 8 p.m., 7 days a week. (TTY/TDD 1-800-421-1220). Or see the Evidence of Coverage for more information.