How is out-of-network defined?
Generally the term Out-of-network refers to the use of providers that are not contracted to provide services to Blue Medicare HMO or Blue Medicare PPO members. In some situations, the use of out-of-network providers is permissible. There are several specific situations in which coverage may be available out-of-network:
What is excluded from out-of-network coverage?
Routine use of an OON pharmacy is not permitted by a member who resides in a location where adequate pharmacy access exists (please refer to the pharmacy access standards). Members are encouraged to use network pharmacies unless one of the specific OON situations listed above applies.
In the situations listed above, will I have prescription drug coverage?
Yes, we will pay up to our allowed amount for the drug minus any applicable copay or coinsurance.
What do I need to do if I need to get a prescription drug at an out-of-network retail pharmacy?
For one of the out-of-network situations described above, you will need to do the following:
What will I be reimbursed?
There are two reimbursement scenarios for the out-of-network benefit. These are:
Please note that in emergency situations, you will be reimbursed the entire amount minus your member cost share amount.
What are the pharmacy access standards?
Medicare categorizes the pharmacy access standards into three categories: urban, suburban and rural. These access standards vary based upon locale as listed below.
How do I know if there is a pharmacy that meets the access standards for where I live?
You can either call the Customer Service number on the back of your ID card and ask the representative, or search our online pharmacy directory.
What drugs and vaccines are generally dispensed and administered in the physician office setting?
Certain drugs and vaccines not covered under Medicare Part B may be covered by Blue Medicare HMO or PPO. In many cases these drugs and vaccines will require prior approval to be requested and approved before coverage can be provided under Blue Medicare HMO or PPO benefit.
Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.
Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.
Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium.
If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.
The information on this page is current as of 10/01/2012.
Y0079_5875 CMS Approved 10012012