OUT-OF-NETWORK COVERAGE

Our Partnership Program has formed a network of doctors, specialists and hospitals.  Members can only use doctors who are part of our network.  There may be times when another physician or specialist who is not in the provider network is needed. Your Team needs to be contacted for those services.  If services are received from a non-network provider without approval from your Team except for emergency/urgent services, the member must pay for these services because the Partnership Program the Original Medicare Plan nor Wisconsin Medicaid will pay for those services.

Our Partnership Program has network pharmacies outside of the service area where plan members can obtain covered drugs. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Before a prescription is filled at an out-of-network pharmacy, your Team should be called to see if there is a network pharmacy available. If there are no network pharmacies in that area, your Team may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, the member would have to pay the full cost (rather than paying just their co-payment) when the prescription is filled and submit a paper claim for reimbursement.  We will also cover a member’s prescription if they 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 or if it is a drug that is not regularly stocked at an eligible network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.