Out-of-Network Service
From time to time a Member will want to use a non-network
provider. The Premier Plan provides coverage
for Out-of-Network service. However, this type of service
generally will result in a higher cost to the Member and the
Plan for the following reasons:
-
Not only will the Member have to pay the deductible
and coinsurance identified and itemized in the
Premier Plan Chart, but the provider’s charges
will generally be higher because the Plan has not
negotiated a discount.
-
If the provider’s charges exceed the reasonable and
customary charge for the procedure, the Plan will
not consider this excess cost in calculating its
reimbursement and the Member will have to pay
this additional cost.
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In-Network providers generally follow medical
procedures which have been certified as effective by
the provider’s Medical Board.
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You will be responsible for ensuring that your provider
follows all Plan medical management procedures in
pre-certifying your care, your hospitalization or other
institutional care and in securing any necessary prior
authorization for prescription drugs.
One should attempt to use In-Network
providers whenever possible in order to
be assured of receiving the highest quality
medical service at the lowest possible total
cost to you and your family.
