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Medical Care and Plan Providers
Medical Services Not Requiring a Referral
or "Self-Referrals"
There are certain times when you may be able to get certain services without a referral. You will get most of your routine or basic care from your PCP. Your PCP can also coordinate your covered services. If you get services from any doctor, hospital, or other health care provider without getting a referral ahead of time from your PCP, you may have to pay for these services yourself. This also includes if you get these services from a provider in your plan.
In some cases, you can get the services listed below without a referral or approval ahead of time from your PCP. "Self-referred" means you get service on your own.
If you get self-referred services, you still have to pay a co-payment. However, if you get a self-referred service from a plan provider, you will only have to pay the in-network co-payment. If you go to a non-plan provider for these services, you will have to pay more.
The following services may be self-referred:
- Routine women's health care, which includes breast exams, mammograms, pap tests, and pelvic exams. This care is covered without a referral from your PCP only if you get it from a plan provider.
- Flu shots and pneumonia vaccinations only if you get them from a plan provider.
- Emergency services, whether you get these services from plan providers or non-plan providers. Emergency services, including hospital care after you are stable (known as post-stabilization), are also covered.
- Urgently needed care that you get from non-plan providers when you are temporarily outside the plan's service area. For more information about urgently needed care, see Emergency, Urgent Care & Care Outside Service Area on this website.
- Renal dialysis (kidney) services that you get when you are temporarily outside the plan's service area. If possible, please let us know before you leave the service area where you are going to be, so we can help arrange for you to have maintenance dialysis while outside the service area.