Benefit Penalties 

The Plan will apply the following benefit penalties in these specified situations:

  • 25% benefit penalty for failure to obtain preauthorization. If you or your provider does not obtain preauthorization when it is required, a 25% benefit penalty (100% benefit penalty for transplants) per event will be added to your share of the medical expenses. In addition, if these services are later found not to be medically necessary (i.e., during retrospective review), claims for reimbursement will be denied.
  • 40% benefit penalty for using a provider that is not a Plan-approved Center of Expertise for a designated procedure.
  • 40% benefit penalty for failure to utilize or cooperate with Care Coordination when required by the Plan. 
  • 100% benefit penalty for failure to obtain preauthorization for a transplant at the time you are referred for a transplant and/or evaluation. In other words, the Plan will not cover any of the transplant expenses.

 

Any benefit penalty will reduce the amounts the Plan would normally pay for applicable expenses, including both medical expenses and prescription drug expenses. For example, if the Plan would normally pay $10,000, a 25% benefit penalty means the Plan would instead pay $7,500 and you would be responsible for the remaining $2,500 (in addition to any cost-sharing you would normally pay, such as deductibles and coinsurance). Benefit penalties do not apply toward any deductibles or out-of-pocket limits.