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Out of Network Coverage

“Out-of-network providers” are providers that are not part of the HealthSun Health Plans network.  If you need care when you are outside the service area your coverage is limited.  The only services we cover when you are outside our service area are for a medical emergency, including maintenance care and hospital care after you are stable (known as post-stabilization), urgently needed services, and renal dialysis (kidney).  We will also cover care that HealthSun Health Plans or a network provider has approved in advance and any other services which were ordered and covered through an appeals process.


If an out-of-network provider asks you to pay for covered services you got in the above mentioned situations, ask the plan provider to bill us first. If you have already paid for the covered services or get a bill for the services, you can send the bill to us for payment. We will review the bill and decide whether the services should be paid. For assistance and additional information please contact our Member Service Department at 305-324-9292 or Toll Free at 1-877-207-4900.  TTY 1-877-206-0500.


When in the service area you must use plan network providers for emergency or urgently needed services.  However, emergency or urgently needed services can always be obtained out of the service area from the nearest available provider.   In addition, when out of the service area you can obtain dialysis treatment from any qualified dialysis provider.  If you obtain routine care from out-of-network providers neither Medicare nor HealthSun Health Plans will be responsible for the costs.


Your prescription may be covered in certain situations

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.  If you cannot use a network pharmacy, we could cover your prescriptions filled at an out-of-network pharmacy if you will be traveling out of the service area.   Please contact the Part D Services Department at (305) 460-3901 for information concerning vacation supplies and authorizations. 


In these situations, please check first with the Member Services Department to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.


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 your normal share of the cost) at the time you fill your prescription.  However, you can request to reimburse you for our share of the cost. Learn how to request a reimbursement.