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Plan Exclusions and Limitations

Plan Exclusions and Limitations

Refer to your plan's Evidence of Coverage, go to Chapter 4, Section 3  to read about benefit limitations and items or services that are not included in your coverage with our plan.

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 our plan authorizes use of out-of-network providers.

Health Net Provider Network Coverage Limitations

HMO Plans
In-network providers are those providers who are contracted with Health Net. Out-of-network providers are those who do not have a contract with Health Net and who accept Medicare. Members enrolled in Health Net Medicare Advantage (MA) HMO plans must receive all routine care from in-network plan providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If Health Net MA HMO members obtain routine care from out-of-network plan providers, neither Medicare nor Health Net will be responsible for the costs. In most cases, you will need to be referred by your primary care physician to receive services from a specialist. If you do not have a referral before you receive services from a specialist, you may have to pay for these services yourself.

PPO Plans
In-network providers are those providers who are contracted with Health Net. Out-of-network providers are those who do not have a contract with Health Net and who accept Medicare. Members enrolled in Health Net MA Preferred Provider Organization (PPO) plans can receive care from out-of-network providers. Receiving care from an out-of-network provider may cost more than receiving care from Health Net's in-network providers, except in emergency or urgent care situations. Health Net will reimburse PPO plan members for mandatory supplemental services received in or out-of-network as long as the services are medically necessary. PPO members do not need a referral if they are going to see an out-of network provider. Again, member copayments for covered services may be more if obtaining services from out of-network providers.

Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please contact us or see the Evidence of Coverage for more information, including cost-sharing that applies to out-of-network services.

The types of pharmacies that are part of the Health Net network include Retail, Mail Order, Specialty, Home Infusion, Long-Term Care (LTC) and Indian Health Service/Tribal/Urban Indian Health Program (I/T/U). To obtain additional network pharmacy information, please contact us.