Using Out-of-Network Pharmacies - 2010

Rules about using non-plan providers to get your covered services

We list the providers that participate with our Plan in our Provider Directory. These providers are called plan providers. Except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis, you must obtain covered services from plan providers for the services to be covered. If you get non-emergency care from non-network providers without a prior authorization, you might have to pay the entire cost yourself.

Our Out of Network Policy

If your provider is not in the Passport Advantage (HMO) network, call us! We can try to work with your provider to see if they would like to join our network. We can also suggest other plan providers who might be a good fit for you.

You can continue to go to your non-plan provider if he or she accepts Kentucky Medicaid and Medicare... however, you might have to pay more out of pocket. To make sure your services are covered, please try to go to a plan provider.

Plan drugs may be covered in special circumstances, for instance, illness while travelling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drugs and submit documentation to receive reimbursement from Passport Advantage (HMO). You can get a 10-day supply of drugs.

Out-of-Network Initial Coverage

Depending on your income and institutional status, you will be reimbursed by Passport Advantage (HMO) up to the full cost of the drug minus the following:

Out-of-Network Catastrophic Coverage

In 2010, after your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed in full for drugs purchased out-of-network.

Filling prescriptions at an out-of-network pharmacy

Sometimes, you may have to go to a pharmacy that is not in our network. The following are a few times when we will pay for your medicine at a pharmacy outside of our network.

• If you are traveling or are away from the plan’s service area
  If you take a medicine on a regular basis and you are going on a trip, be sure to check your supply of the medicine before you leave. Take all of the medicine that you will need for the trip. If you go on a trip, Passport Advantage will only cover medicines in some situations. If you want to go to a pharmacy that is not in our network, it must be in the United States. Also, we will only cover your medicines in the following situations:
  • You become ill
  • You lose your medicines
  • You run out of your medicines
• If you need medicine for a medical emergency
  You can go to an out-of-network pharmacy if the medicines are needed to care for a medical emergency or urgent care.
• Other situations
  We will cover your medicines at an out-of-network pharmacy in the following situations:
  • If you cannot get a covered medicine in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
  • If you are trying to get a medicine that is not regularly stocked at an accessible network pharmacy (including high cost and unique medicines).

You may go to doctors, specialists, and hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances when they cannot reasonably use network pharmacies. Passport Advantage has retail, long term care, and home infusion pharmacies available in our network. In general, Part D benefits are only available at contracted network pharmacies. For additional network pharmacy information, please call our Member Services.