Medicare Medicare

Out-of Network Coverage Rules

 

HMO-POS

  • While you are a member of our plan you must use network providers to get your medical care and services
  • The only exceptions are emergencies, urgently needed care when the network is not available (generally when you are out of the service area), out-of-area dialysis services and cases in which SelectSaver  HMO authorizes use of out-of-network providers (your provider must obtain authorization from us)
  • In addition, Point-of-Service (POS) members have the option to get select medical care and services from an out-of-network provider at an additional cost.  (Certain benefits covered up to $2,500 per year)

oEmergency care, urgently needed care and out-of-area dialysis do not count towards the benefit maximum.

 

Prescription Drug

  • You generally must use a network pharmacy to fill  your prescription
  • We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.
  • Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.  Here are the circumstances when would cover prescriptions filled at an out-of-network pharmacy:

o There are not network pharmacies within a reasonable driving distance that provides 24 hour service

o If you are trying to fill a prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy

  • Always check with member services to see if there is a network pharmacy nearby.

If you move out of the area that HealthNow New York serves, you must notify the plan so you can disenroll and find a new plan in your new area.  If you permanently live out of the service area for longer than six months, you are no longer eligible to be enrolled in our plan.

 

For more information about out-network coverage and cost sharing refer to the Summary of Benefits or the Evidence of Coverage.

 

 




This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year.  The Formulary, pharmacy network, and/or provider network may change at any time.  You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

 

HealthNow New York Inc.  is a Medicare Advantage and stand-alone PDP plan with a Medicare contract. Enrollment in HealthNow New York Inc. depends on contract renewal. 

 

Y0086_MRK1600 Approved 

Content Last Updated January 19, 2016

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