Learn About Out-of-Network Coverage
Keystone First VIP Choice (HMO SNP) members must receive care from an in-network provider. 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. There are a few exceptions when an out-of-network provider will be covered.
The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
What is a medical emergency?
A "medical emergency" is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
What is urgent care?
Urgent care is care for a non-emergency, unexpected medical illness, injury, or condition that requires immediate medical care. Urgent care may be given by in-network providers. It may also be given by out-of-network providers when network providers are not available right away. For example, you may get care if spraining an ankle or cut a finger while out of the service area, or you might have a flare-up of an existing condition and need to have it treated.
What if you can not get care from your network provider?
If you need medical care and Medicare requires our plan to cover it, and if the providers in our network can not give you this care, you can go to an out-of-network provider. You must get approval before getting this care from an out-of-network provider. If this happens, we will cover these services as if you got the care from a network provider. To get approval, you or your provider must contact Keystone First VIP Choice. You will need to provide information on why the services are not available from the provider network.
If you have questions, call Member Services at 1-800-450-1166 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.
When can you use a pharmacy that is not in the plan's network?
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:
- If the prescriptions are related to care for a medical emergency or urgent care.
- If you are unable to obtain a covered drug in a timely manner within our service areas because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs).
- If it is one of the covered drugs that can be administered in a doctor's office.
In these situations, check first with Member Services to see if there is a network pharmacy nearby. You can call Member Services at 1-800-450-1166 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost at the time you fill your prescription. You can ask us to reimburse you.
Learn how you can get back the money you spent on a prescription.