With our plans, you have access to thousands of doctors, hospitals and pharmacies:
The pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
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.
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.
Out-of-network/non-contracted providers are under no obligation to treat Excellus BlueCross BlueShield members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Customer Care number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
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:
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 Customer Care toll-free at 1-877-883-9577, (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. 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.