Out-of-Network Coverage

Out-of-Network Medical Coverage

With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Care1st Health Plan authorizes use of out-of-network providers.

You are responsible for paying the full cost of services that were obtained out-of-network where not authorized.

Please refer to Chapter 3 of the Care1st Health Plan Evidence of Coverage for full information on out-of-network medical coverage.

Evidence of Coverage
Rights and Responsibilities (Disenrollment)

Out of Network Prescription Drug Coverage

Using a pharmacy that is not in the Care1st Health Plan network

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:

In these situations, please check first with Member Services at 1-800-544-0088 (TTY 1-800-735-2929) from 8:00 a.m. to 8:00 p.m., seven days a week, to see if there is a network pharmacy nearby.

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 (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost.