Out-of-Network Coverage and Care

Out-of-Network Medical Care

There are a few situations where you can receive medical care from a provider who is not in the Optima Medicare network. Here are some examples when you can do this:

  • If you need emergency or urgent care;
  • If you have End-Stage Renal Disease and need dialysis services, and are outside of the Optima Medicare service area;
  • If your Optima Medicare provider notifies us that they are leaving our network, we will let you know. If you are in critical stage of a current course of treatment that would be best continued with your current provider, you can ask us for approval to keep seeing this provider for up to 90 days. We can also help you transition your care to an Optima Medicare provider;
  • If you need specialized treatment or a procedure that is only done by a few providers and none of these providers are in our network, you or your current provider can ask us for approval to see this new provider. If we find that the service is available by an in-network provider, you may be redirected to one of our in-network providers.

Traveling outside of the country? As of January 1, 2019, Optima Medicare covers emergency and urgently needed care outside of the United States and its territories.  Please see information below for pharmacy coverage.


Out-of-Network Pharmacy Coverage

Optima Medicare HMO members are guaranteed out-of-network access to prescription drugs when they are within the United States and:

  • Traveling outside the plan’s service area and run out or lose the covered Part D drugs or become ill and need a covered Part D drug, and cannot access a network pharmacy;
  • Not able to obtain a covered Part D drug in a timely manner within the plan’s service area because, for example, there is no network pharmacy within a reasonable driving distance that provides twenty-four hour service;
  • Filling a prescription for a covered Part D drug and that particular drug (for example, an orphan drug or other specialty pharmaceutical) is not regularly stocked at an accessible network retail or mail-order pharmacy;
  • Provided covered Part D drugs dispensed by an out-of-network institutional-based pharmacy while a patient in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.

*Please refer to your Evidence of Coverage (EOC) Chapter 5, Section 2.5 for more information on out-of-network coverage.

Traveling outside of the country? Optima Medicare does not pay for any prescriptions that are filled by pharmacies outside of the United States. As of January 1, 2019, if you receive medications during an emergency or urgent care visit, these medications are covered as part of the visit costs under your Optima Medicare medical benefits.  Prescriptions you might receive from a provider at an emergency or urgent care visit that needs to be filled at a pharmacy outside of the United States are not covered.