Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, we may reimburse certain travel expenses. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. Health Care Services from Out-of-Network Providers If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. SAMPLE If Behavioral Health Care Services are not available from a Network provider in a Timely Manner, you will be eligible to receive Covered Health Care Services from an out-of-Network provider at the same cost share as if received from a Network Provider. In this situation, we will work with you to coordinate care through an out-of-Network provider in a Timely Manner as defined within the Policy. Outpatient Prescription Drugs Schedule of Benefits When Are Benefits Available for Prescription Drug Products? Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance or other payments that vary depending on which of the tiers of the Prescription Drug List the Prescription Drug Product is placed. Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of a Covered Health Care Service. What Happens When a Brand-name Drug Becomes Available as a Generic? If a Generic becomes availab...
Designated Providers. The Medical Plan provides coverage for counseling in areas such as mental illness, alcohol and other drug abuse, marriage, debt (financial), and family support. To be eligible for coverage, counseling must be provided within the designated network. Refer to the Medical Summary Plan Description for specific benefits and eligibility requirements.
Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. Health Care Services from Out-of-Network Providers If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider.
