Why do you need to know which providers are part of our network?

It is important to know which providers and pharmacies are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers and pharmacies to get your medical care and services and prescriptions.  The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Passport Advantage authorizes use of out-of-network providers.

You must receive your care from a network provider.  In most cases, care you receive from an out-of network provider (a provider who is not part of our plan’s network) will not be covered. Here are three exceptions:

  • The plan covers emergency care or urgently needed services that you get from an out-0f-network provider.  For more information about this, and to see what emergency or urgently needed services mean, see Section 3 of Chapter 3 of the 2017 Evidence of Coverage.
  •  If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider.  Authorization should be obtained from Passport Advantage prior to seeking care from an out-of-network.  In this situation, we will cover these services as if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 of Chapter 3 of the 2017 Evidence of Coverage.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

How to get care from out-of-network providers

While you are a member of our Plan, you must use our network providers to get your covered services except in limited cases such as emergency care, when providers of specialized services are not available in network, or out of area dialysis. If you need to use providers who are not in our network, you must call us first for authorization. Otherwise, you may have to pay more. We list the providers that participate with our Plan in our Provider and Pharmacy Directory.

If you get non-emergency care from non-plan (out-of-network) providers without prior authorization, you may have to pay the entire cost yourself. If an out-of-network provider sends you a bill that you think we should pay for, please contact Member Services.

When can you use a pharmacy that is not in the plan’s network?

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, here are the circumstances when we would cover prescriptions filled at an out-of network pharmacy:

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provides 24-hour services.
  • If you are trying to fill a covered drug that is not regularly stocked at an eligible network retail pharmacy. (These drugs include orphan drugs or other specialty pharmaceuticals).
  • Please note that out-of network prescriptions are limited to reimbursement for a single refill of up to a 10-day supply. If you are planning an extended stay in an area without a network pharmacy, please call our Member Services Department for assistance in signing up for mail order services.
  • If you are filling prescriptions at an out-of-network pharmacy related to a medical emergency.

In these situations, please check first with Member Services 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.

 

 

Last Modified: October 13, 2017