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Out of Network Coverage (Part C)

Out-of-Network (OON) Provider Access

In most cases, the care and services that you receive will be provided by our network providers. Usually, the plan will not cover care from a provider who is not in network with MeridianComplete.

Here are a few cases where this rule does not apply:

  • The plan covers emergency or urgently needed care from an out-of-network provider.
  • If you need care that is covered by MeridianComplete and our network providers cannot give it to you, you can get the care from an out-of-network provider. If you are seeking care from an out of network provider, an authorization is required. In this situation, we will cover the care as if you got it from a network provider.
  • The plan covers kidney dialysis services when you are outside the plan’s service area for a short time. You can get these services at a Medicare-certified dialysis facility. 
  • When you first join the plan, you can keep receiving services and seeing the doctors and other providers you go to now for at least 90 days from your enrollment start date. If you receive services through the Habilitation Supports Waiver or the Specialty Services and Supports Program through the PIHP, you will be able to receive services and see the doctors and providers you go to now for up to 180 days from your enrollment start date. Your Care Coordinator will work with you to choose new providers and arrange services within this time period.
  • During any state or federal disaster declaration or other public health emergency declaration in which the member is evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered services at a network provider

Out-of-Network (OON) Pharmacy Access

MeridianComplete reimburses members for Part D drug expenses incurred at out-of-network pharmacies in the following situations:

  • The member is traveling outside of the MeridianComplete service area; runs out of or loses his or her covered Part D drug, or becomes ill and needs a covered Part D drug; and cannot access a network pharmacy
  • The member cannot fill a prescription for a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-a-week service
  • The member must fill a prescription for a covered Part D drug in a timely manner, and the particular covered Part D drug (for example, an orphan drug or other specialty pharmaceutical typically shipped directly from manufacturers or special vendors) is not regularly stocked at accessible network retail or mail-order pharmacies
  • The member is provided covered Part D drugs dispensed by an OON institution-based pharmacy while he or she is a patient in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting, and as a result cannot get their medication filled at a network pharmacy
  • The member is receiving a vaccine that is medically necessary but is not covered by Medicare Part B that is appropriately dispense and administered in a physician office
  • During any state or federal disaster declaration or other public health emergency declaration in which the member is evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy
  • MeridianComplete applies OON policies for unexpected situations in which normal distribution channels are unavailable

Before obtaining a covered Part D drug through an OON pharmacy, it is the responsibility of the member:

  • To contact MeridianComplete to ensure that there are no network pharmacies within reasonable distance where he/she can fill the prescription

When a member uses an OON pharmacy, the pharmacy may not be able to submit the claim directly to MeridianComplete. In this instance, the member is required to pay the OON pharmacy’s usual and customary (U&C) price at the point-of-sale and submit a written request for reimbursement to MeridianComplete. The pharmacy may also contact MeridianComplete to obtain an OON pharmacy override.

Note: If a member uses an OON pharmacy, the member may be financially responsible for the sum of:

  • Any deductible or cost-sharing
  • Any differential between the OON pharmacy’s U&C prices and the MeridianComplete negotiated in-network charge for the medication

Exclusions

MeridianComplete does not reimburse members for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency.

MeridianComplete does not reimburse members for any fee or charge for vaccine administration that falls entirely outside the Part D cost sharing structure.

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