Out-of-Network Coverage

Today's Options^® PPO has established a network of providers. We contract with network providers for all services covered under Original Medicare. You may receive covered services from out-of-network providers (those who do not have a signed contract with our plan), provided that those providers agree to accept the plan's terms and conditions of payment.

Today's Options PPO 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.
• The care you receive is from a provider who participates in Medicare.

Out-of-Network Providers

You may be able to receive care from an out-of-network provider. However, the provider must participate in Medicare and your cost-sharing for services that are covered by the plan may be higher. If you receive care from a provider who does not participate in Medicare, you could be responsible for the full cost of services received.

You do not need to obtain a referral or prior authorization in order to receive care from out-of-network providers. However, Today's Options PPO suggests calling Member Services, prior to receiving care and services from a provider, in order to confirm that the services are covered by the plan and are medically necessary.

Emergency and Urgent Care

Today's Options PPO 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 PPO Medicare Advantage Prescription Drug Plan)

Today's Options PPO 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 1-866-422-5009, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-877-907-2985) 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.