Out-of-Network Coverage

Today's Options^® HMO has established a network of providers. We contract with network providers for all services covered under Original Medicare.

Today's Options HMO will generally cover your medical care provided that:

• The care you receive is part of the plan's Medical benefits. For a complete list of plan benefits please refer to the Evidence of Coverage.
• The care you receive is considered medically necessary and is a recognized and accepted treatment for the medical condition you receive care for.
• You have a Primary Care Physician (PCP) who provides and oversees your care
• In most cases, prior to receiving care from other providers in the network (such as specialists, hospitals, or skilled nursing facilities), your PCP has provided approval.
• If you need to receive care from a provider outside of the plan's network, Today's Options HMO's Medical Director has approved your PCPs recommendation to do so.

You must use plan providers except in emergency or urgent care situations. If you obtain routine care from out‐of‐network providers neither Medicare nor Today's Options HMO will be responsible for the costs.

Emergency and Urgent Care

Today's Options HMO will cover emergency and urgent care if you are outside of the plan's service area. If you use an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, your cost-sharing will not be higher.

Out-of-Network Pharmacy Coverage (if you have a Today's Options HMO Medicare Advantage Prescription Drug Plan)

Today's Options HMO has formed a network of pharmacies. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

• The pharmacies in our network can change at any time.
• You can use our Pharmacy Locator or call us at 1-866-802-8571, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week, for an up-to-date list.
• Formulary medicines may be covered in special circumstances, such as illness while traveling outside of the plan's service area (within the United States) where there is no network pharmacy.
• You may pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy.
• We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. For example, you may submit a claim for a Part D covered medication dispensed by a nonparticipating pharmacy for the following reasons:
• If you traveled outside of the plan's service area and ran out of (or lost) your medication or if you became ill and could not access a network pharmacy.
• If you were unable to obtain your medication in a timely manner within the service area. For example, there was no network pharmacy within a reasonable driving distance that provides 24/7 service.
• If your medication is not stocked regularly at an accessible network pharmacy.
• If your medication was dispensed from an emergency department, provider-based clinic, outpatient surgery facility, or other outpatient setting.
• If you received a vaccine at your doctor's office.
• If you were evacuated or displaced from your residence due to a state or federally declared disaster or health emergency.

Download the Direct Claims Form (PDF) to submit a claim for a Part D covered medication dispensed by a non-participating pharmacy.