Out-of-Network Pharmacy Coverage

Optima Medicare HMO members are guaranteed out-of-network access to prescription drugs when they are:

  • 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.