Out-of-Network Coverage

Out-of-Network Medical Coverage

With limited exceptions, while you are a member of our plan you must use network providers to get your 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 area), out-of-area dialysis services, and cases in which Blue Shield Promise Cal MediConnect Plan authorizes use of out-of-network providers.

You are responsible for paying the full cost of services that were obtained out-of-network where not authorized.

Please refer to Chapter 3 of your Evidence of Coverage for full information on out-of-network medical coverage.


Out of Network Prescription Drug Coverage

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

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:

  • In emergency situations
  • When you are out of the service area for up to but no more than six months.
    • 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 an out-of-network pharmacy than what you would have paid if you had gone to an in-network pharmacy. Reimbursement for out-of-network pharmacy claims will be made at our contracted rates. The difference will be your responsibility

In these situations, please check first with Blue Shield Promise Cal MediConnect Plan Member Services at (855) 905-3825 (TTY: 711), from 8:00 a.m. to 8:00 p.m., seven days a week, to see if there is a network pharmacy nearby.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost.



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