Going Out-of-Network: “Allowed Amount” Defined

The “allowed amount” is the amount that your insurance carrier will allow for a participating provider even when the services are rendered out-of-network. Out-of-network charges can be significantly greater than the allowed amount and you will be responsible for the difference between what the out-of-network provider charges and what your insurance carrier reimbursed. These balanced billed charges do not accumulate towards your out-of-network deductible or out-of-pocket maximum.

Utilization Review

All hospital confinements and surgeries must be preauthorized by your insurance carrier. You or your physician must call your insurance carrier prior to a hospital admission for non-emergency treatment. If you do not obtain this mandatory authorization, your benefits will be reduced or a penalty payment will apply. Refer to your ID card for the utilization review phone number and required time frame for reporting.

Claims

In-network providers will submit claims directly to your insurance carrier. If you see an out-of-network provider, you may be required to submit the claim directly to your insurance carrier for reimbursement.

Brand Name Prescription Drug Warning

In some cases, if you choose to receive a brand name drug when a generic equivalent is available, you may be responsible for the generic drug cost plus the difference in cost between the generic and the brand name negotiated rate. Refer to your specific plan documentation to confirm the specific prescription drug provisions of your plan.