Non-network medical coverage

As a Blue Shield of California Promise Health Plan member, you must use network providers to get your medical care and services. The only exceptions are:

  • Emergencies 
  • Urgently needed care when a network provider is not available (generally, when you are out of the area)
  • Out-of-area dialysis services
  • Cases in which Blue Shield Promise Cal MediConnect Plan authorizes use of non-network providers

You are responsible for paying the full cost of services for unauthorized non-network services.

Please refer to Chapter 3 of your plan's Member Handbook for full information on non-network medical coverage.

Non-network prescription drug coverage

Using a pharmacy that is not in the Blue Shield of California Promise Health Plan network

Blue Shield of California Promise Health Plan has a network of pharmacies outside of its service area where you can get your prescriptions filled. Generally, we cover drugs filled at a non-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at a non-network pharmacy:

  • Emergency situations
  • When you are out of the service area for up to six months

In these situations, please check first with Member Services to see if there is a network pharmacy near you.

We recommend that you fill all prescriptions prior to traveling out of the area so that you have an adequate supply. If you need assistance with obtaining an adequate supply prior to your departure, please contact Member Services.

You may pay more for any drugs you get at a non-network pharmacy than you would have paid at an in-network pharmacy. We reimburse for non-network pharmacy claims at our contracted rates. The difference will be your responsibility.

Blue Shield of California Promise Health Plan Member Services:
Phone: (855) 905-3825 [TTY: 711], 8 a.m. to 8 p.m., seven days a week

If you must use a non-network pharmacy, you will generally have to pay the full cost (rather than paying your normal cost share) when you fill your prescription. You can ask Blue Shield of California Promise Health Plan to reimburse you for its share of the cost. For more information on how to request payment, see Organization determination for reimbursement