Out-of-Network Coverage

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 Community Complete (HMO SNP) 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 Community Complete service area;
  • If your Optima Community Complete 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 Community Complete 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.

Note: Optima Community Complete only provides care within the United States and its territories.

Out-of-Network Pharmacy Coverage

Optima Community Complete 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.