Plan Exclusions and Limitations

Click the Evidence of Coverage link below and go to Chapter 4, Section 3  to read about benefit limitations and items or services that are not included in your coverage with our plan.

Evidence of Coverage - Chapter 4 - Plan Exclusions and Limitations

While you are a member of our plan you must use network providers to get your 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 area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers.

Out of Network Coverage Rules

Medical Care

If your primary care provider determines that you need Medicare required medical care that is not available within our network, your primary care provider will obtain plan authorization for you to see an out-of-network provider. You must have plan authorization prior to seeking care from an out-of-network provider for services to be covered. You will pay the same for authorized out-of-network services as you would pay if you got the care from a network provider.

Prescription Drugs

If your plan pays for prescription drugs, and you use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill the prescription. You can ask us to reimburse you for our share of the costs.


Last Updated: 10112016
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