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Out-of-Network Policy for HMO Members

• Alignment Health Plan HMO members must receive care from a network provider.
  A

  In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. You are responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan-covered services or they were obtained out-of-network and were not authorized.

  Here are three exceptions:

  1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
  2. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Prior authorization is required before you get care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, please refer to your Evidence of Coverage.
  3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.

• When can you use a pharmacy that is not in the plan's network?
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  Your prescription may be covered in certain situations

  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 we would cover prescriptions filled at an out-of-network pharmacy:

  1. If you are unable to get a covered drug in a timely manner within our service area, because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  2. If you are trying to fill a covered prescription drug that is not regularly stocked at a network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

  In these situations, please check first with Member Services to see if there is a network pharmacy nearby.

• How do you ask for reimbursement from the plan?
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  If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please refer to your Evidence of Coverage for a description of how to ask the plan to pay you back.

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