Reimbursement for covered services provided by out-of-network providers and suppliers. Out-of-network benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket costs. Depending on your contract, out of network services may not be covered. Please refer to your contract for specific benefit coverage.
Covered services that are not provided, rendered or referred by your Primary Care Physician.
The benefits you receive when you use a health care provider who is not part of the network (out-of-network provider). Typically, you pay more when you use an out-of-network provider.
Services received from providers not in your Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) or Drug Plan network or panel. PPO and Point-of-Service (POS) plans cover out -of- network services, but with deductibles and co-insurance.
Generally, an out-of-network benefit provides a beneficiary with the option to access plan services outside of the plan?s contracted network of providers. In some cases, a beneficiary?s out-of-pocket costs may be higher for an out-of-network benefit.
Under most HMO-based plans, you are not reimbursed for any services provided by a hospital or doctor who does not participate in the plan's network. With PPO-based plans, there may be a provision for reimbursement of "out-of-network" providers, but this usually involves higher copays and/or lower reimbursements.