Medicare Advantage Out-of-Network Coverage Rules



  • You must get all of your health care from doctors in our network.
  • With limited exceptions, while you are a member of our plan you must use network providers to get 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 service area), out-of-area dialysis services and cases in which Senior Blue HMO authorizes use of out-of-network providers (your provider must obtain authorization from us).
  • As a member of our plan, you can choose to receive care from out-of-network providers.
  • Our plan will cover services from either in-network or our-of-network providers, as long as the services are covered benefits and medically necessary.
  • If you use an out-of-network provider, your share of the costs for your covered services may be higher.
  • If you are using an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount (these amounts will count towards the combined in and out-of-network out of pocket maximum of $10,000).
  Prescription Drug:
  • You generally must use a network pharmacy to fill your prescription.
  • 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:
    • There are not network pharmacies within a reasonable driving distance that provides 24-hour service
    • If you are trying to fill a prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy
  • Always check with member services to see if there is a network pharmacy nearby.

If you move out of the area that BlueCross BlueShield of Western New York serves, you must notify the plan so you can disenroll and find a new plan in your new area.  If you permanently live out of the service area for longer than six months, you are no longer eligible to be enrolled in our plan.

For more information about out-of-network coverage and cost-sharing, refer to the Summary of Benefits or the Evidence of Coverage.


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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of Western New York 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 service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueCross BlueShield of Western New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

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Y0086_MRK1961 Approved
Content Last Updated October 1, 2017