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 as a member of our plan you must use network providers and pharmacies to get your medical care and prescriptions. In Network providers are physicians, facilities and pharmacies that Passport Advantage has contracted with to provide you with your health care services.

Out of Network providers are physicians, facilities and pharmacies that are not contracted with Passport Advantage to provide you with your health care services.

Are there exceptions?

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.

Below are the limited circumstances:

  • The plan covers emergency care or urgently needed services that you get from an out-of-network provider.  For more information about this, and to see what emergency or urgently needed services mean, see your Evidence of Coverage.
  •  If you need medical care that Medicare requires our plan to cover but the providers in our network cannot provide this care, you may be able to obtain authorization for this care from an out-of-network provider.  Authorization should be obtained from Passport Advantage prior to seeking care from an out-of-network provider.  If approved, we will cover these services as if you got the care from an in network provider. For information about getting approval to see an out-of-network doctor, see your 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.

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

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 may have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.

Your prescription may be covered in certain situations if you cannot use a network pharmacy. Below 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).
  • 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.

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.

 

Last Modified: December 13, 2017