WALGREENS AND COSTCO PHARMACIES

Walgreens and Costco are not covered pharmacies for Advantage Health Plans Trust. Members of AHPs MUST use an in-network pharmacy. Out-of-network pharmacy claims are non-covered.

BAYLOR SCOTT & WHITE PROVIDERS

Specific Baylor Scott & White providers may be excluded from your PPO network. Claims submitted by providers with certain tax ID numbers affiliated with Baylor Scott & White, may be processed as OUT-OF-NETWORK.

These providers may appear as though they are participating in your network based on the network search results. To view a list of excluded providers, please click here.

Claims from these Baylor Scott & White providers will be processed as out-of-network and will be reimbursed based upon AHP’s Reference Based Price (RBP) limitations.

The Reference Based Price reimbursement is calculated on a percentage above the specific provider’s Medicare reimbursement for that service.

• Physicians will be reimbursed 100% of their Medicare allowable, plus an additional 20%.
• Facilities and Hospitals will be reimbursed 100% of their Medicare allowable, plus an additional 50%.
• Emergency services will be reimbursed 100% of their Medicare allowable, plus an additional 100%.

*This list is accurate as of the date indicated, and is subject to change. This list, and all PPO network lists, are for review purposes only and are never a guarantee of benefits. For benefit information or to confirm the status of a network provider, please call us at (800) 324-9396. Benefit determinations are based on the Summary Plan Description.

HENDRICK MEDICAL CENTER

Hendrick Medical Center is excluded from your PPO network. Claims submitted by this provider will be processed as OUT-OF-NETWORK.

These will be processed as out-of-network and will be reimbursed based upon AHP’s Reference Based Price (RBP) limitations.

The Reference Based Price reimbursement is calculated on a percentage above the specific provider’s Medicare reimbursement for that service.

• Physicians will be reimbursed 100% of their Medicare allowable, plus an additional 20%.
• Facilities and Hospitals will be reimbursed 100% of their Medicare allowable, plus an additional 50%.
• Emergency services will be reimbursed 100% of their Medicare allowable, plus an additional 100%.

Remember: Amounts exceeding Plan limitation are non-covered, and you may be balance billed.

This provider may appear as though they are participating in your network based on the network search results.